BASICPEDIA-complete (1).pdf

BASIC

PEDIATRICS

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Growth and Development growth periods Lecturer: Dr. De Guzman Prepared by: cmgt

2 major growth periods: Prenatal & Postnatal I. PRENATAL A. Ov Ovum um B. Emb Embryo ryo C. Fetus Early Fetal life Late Fetal life

0-280 days 0-14 days 3-8 wee weeks ks 9 wee weeks ks to birt birth h nd 2 trimester 3rd trimester

Birth - ave. 280days (37-42weeks is considered a term pregnancy) Premature infant - Less than 37weeks Ex: If the baby is born even it is less than 25weeks 25weeks old, it is already an INFANT. PRENATAL PERIOD PRENATAL A. Ovum • from fertilization to implantation of blastocyst in the uterine wall

1 | prepared by cmgt

• first 14 days • determine whether the pregnancy is viable or not. • Not susceptible to teratogens (agents harmful to pregnancy ex.radiation can not affect the ovum) • organ formation: no significant event B. Em Embr bry yo • All organs form • Morphogenesis - body formation • First 2 organs to form: Brain & Heart • Babies born with congenital rubella - mothers had german measles during pregnancy it is not unusual that the brain & heart are affected at the same time bec they were dev @ the same period. • Formation of ectoderm (skin & CNS), endoderm (CVS & the rest of the organs), mesoderm (respiratory, urinary, digestive tracts, muscles, CT, bones) and their derivatives.

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S C I R T A I D E P C I S A B

Growth periods prenatal and postnatal ...cont. ... cont. embryo

Dev. of sex organs (Dev is diff from determination.) • Dev. Sex is developed (whether the child is going to be masculine/fe mi minine) nine) in the emb ry ryonic onic period. period: • At the end of embryonic period: 3cm, 3grams at 8 weeks • Very vulnerable to teratogens • At 4 weeks the heart starts beating • At 8 1/2 weeks the embryo responds to tactile stimulation. C. Fetus • Time of rapid growth • 13th-15th week: swallowing and suckling movements movt sometimes sometimes quickening ) fetal movt • 16th-20th week: ( quickening felt by the mother • 20th week: - complete commissures commissures of the brain - myelina myelination tion of the cord begins - Present sucking reflex - First patterns of respiratory movement movementss • Vulnerable to teratogens but to lesser extent than embryonic stage • 25-28 weeks: - 38cm (15”) in length - 1.2 kg (2 lb & 11 oz) oz) - Rapid dev of nervous system system - Development of greater control over movements movements such as opening & closing of eyeli eyelids ds & other body functions. - Lungs have developed sufficiently that air breathing is possible • 28th weeks: - retinal layers & light perception complete - eyelids are open

LENGTH AND WEIGHT GAINS weeks

len th

wei ht

8

1”

1/30 oz

12

3’’

1 oz

16

6’’

4 oz

20

10”

1 lb

24

12”

2 lb

28

15”

3 lb

32

17”

4 1/2 lb

36

18”

7 1/2 lb

gestational age; length&we gestational length&weight; ight; chance of survival • At birth: ave weight is 3 kg ~ 6.6 lb Ave length is 50 cm ~ 20” •


II. POST NATAL A. In Infa facy cy Neonate/newborn Neonate/n ewborn Middle/nursingg Middle/nursin Transition/toddler/ runabout B. Chi Childh ldhood ood Early Late

birth to 2 years first 4wks afterbirth 1 st year 1 to 2 years

2-6 years 6-10years (girls) 6-12years(boys)

C. Ado Adoles lesce cence nce

Growth and Development physical development 1st and 2nd year 1st year 1st year 0-2 months ! 10% decrease below birthweight during the first 10 days, which which is physiologic, due to loss of fluid during pregnancy pregnancy.. Exceed birthweight by 2 weeks of age birthweight ! day during the first month (fastest ! 30g/1oz. per day during postnatal growth) 2-6 months months, growth of 20g/day ! by 3-4 months, birthweightt at 4 th month ! doubling of birthweigh ! Ex: ave birthweight = 3 kg @ 4 months = birthweight x 2 = 3kg x 2 = 6 kg 6-12 months st ! by the 1 birthday: ! tripled birthweight ! length has increased by 50% ! head circumference increase by 10cm ! Ex: ave birthweight = 3 kg @ 1 year = birthweight x 3 = 3kg x 3 = 9 kg 2nd year 12-24 months nd ! growth rate slows further in the 2 year of life as appetite declines (due to there’s so much more to do than eating) increase of 5” and 5 lb ! (minimal) increase children are about 1/2 of their ! by 24 months, children ultimate or adult height ! Ex. Adult height = 5’2” During 24 months height is 2’6” ! head growth slows slightly circumference is achieved achieved ! 90% of adult head circumference ! Brain growth with continuing myelination

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Physical development preschool and childhood Preschool ! 3-5 years old or early childhood ! Somatic & brain growth slow down ! Decrease in appetite & nutritional req. eating (a matter matter of assertion of ! “picky” eating independence - the only thing they can control is the amt of food they eat) eat) ! Gain of 2kg (4-5 lb) in weight and 7-8cm (2-3”) in height PER year additional of 5cm between ages ! Head grows an additional 3-18years ! Genu valgum (knock knees) and wild pes planus (flat foot) - normal ! Torso slims as the legs lengthen ! Physical energy peaks, need for sleep declines (11-13hrs/day) vs newborns (20-22hrs/day) ! dropping of nap Childhood ! 6-10 or 12 years old ! Growth of 3-3.5 kg (7 lb) & 6-7cm (2.5”) ! Growth occurs discontinuously, irregular spurts ! Slowing of brain growth = 2-3cm gain for the entire period. ! myelination is complete by 7 years ! Body habitus more erect, long legs longer face ! Gradual growth of mid-face and longer teeth, eruption eruption of first molar at ! Loss of deciduous teeth, 6 years ! Lymphoid tissues hypertrophy (tonsils are normally large at this age; appendectomy is common because appendix gets too big)


Muscular strength, stamina, & coordination increase ! Organize sports advisable @ 6yo (ex.soccer) ! Competitive sports advisable @ 8yo (ex.taekwondo) ! Swimming is advisble @ 5yo !

Ex. of developmental milestones 1 month old - fist fisted ed hand handss 3 month old - play playing ing with with hands hands - turn to side side 4 months old - turn to prone prone 6 months old - can reach reach and play with feet - can sit sit with suppo support rt 8 months - can sit withou withoutt support support 12 months old - can stand

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Growth and Development

growth measurements weight and length LENGTH / RECUMBENT HEIGHT • To measure the height, 2 boards that you can push forward or backward to be able to position the infant well. • Increase in height: Birth - 3months 9 cm Note! 4 - 6 months 8 cm Ave birthwt is 50cm ~ 20” 7 - 9 months 5 cm Conversion: 1” = 2.54cm 10-12 months 3 cm

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WEIGHT • simple, reproducible growth parameter • weight can serve as an index of ACUTE nutritional depletion • In CHRONIC nutritional problem, the parameter used is height • For infants below 6 months:

         

• Total increase in Ht from 0-12months is: 9+8+5+3 = 25 cm Examples: • 1. At end of 1st yr, an infant is expected to measure:       

Ht = birth-length + ( 9+8+5+3) Ht = 50cm + 25cm = 75cm 2. A 9 month old infant is expected to measure: Expected inc in length = 9+8+5= 22cm

Ht = birth-length + ( 9+8+5) Ht = 50cm + 22cm = 72cm

• For infants 6-12months:          

3. What is the ideal length of a 5-month old?

• For 2yo up:           Example (ideal body weight): 1.) A 5 month old infant is expected to weigh: Weight = 5months x 600 + 3000g = 6000g ~ 6kg

Remember: Height/length is cumulative it cannot stay the same in mos 4-6. There should be an increase in length during the 3-month period. So divide the expected inc in ht by 3 to get the expected inc for each month.

Ht = 50 + [ 9 + (2.67 + 2.67) ] = 64.34 cm Age

Inc in Ht

÷3

2.) A 9 month old infant is expected to weigh: Weight = 9mos x 500 + 3000g = 7500g ~ 7.5kg Birth-3mos

9cm

3 cm

@ 0 (birth) 1 mo 2 mos 3 mos

4-6 mos

8cm

2.67cm

@ 4 mos - 2.67 cm 5 mos - 2.67 cm 6 mos - 2.67 cm

3.) 4 year old child is expected to weigh: Weight (Kg) - 4yo x 2 +8 = 16kg AGE AND WEIGHT CHANGE age

weight change

4-5

2x birthweight

1

3x birthweight

2

4x birthweight

3

5 x birthweight

5

6 x birthweight

7

7 x birthweight

10

10 x birthweight

Ex. Ave birthweight = 3000g ~ 3kg (use this if birthweight is not given) @ 10yo = (3kg) x (weight change of 10x) 10yo = 3 x 10kg = 30kg

Increase in height 0 cm 3 cm 3 cm 3 cm

7-9 mos

5cm

1.67cm

@ 7 mos - 1.67 cm 8 mos - 1.67 cm 9 mos - 1.67 cm

10-12mos

3cm

1 cm

@ 10 mo - 1 cm 11 mos - 1 cm 12 mos - 1 cm

• For older children:                     

• At 1 yr 2 yrs 3 yrs 4 yrs 13 yrs

30” 1/2 of mature height 3 ft tall 40” or 2x the birth-length 3x the birth-length

• Example: @ 13 yrs a child is: 3 x 50 cm = 150 cm


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Growth measurements head teeth chest

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HEAD CIRCUMFERENCE


• • • •

•

NUMBER OF TEETH • Expected # of teeth = age in months - 6 • example: 8 months old is expected to have ___ teeth. Average Hc at birth - 14”(13.5”-14.5”), 34cm (33-35cm) # of teeth = 8mos - 6 = 2 teeth routinely taken up to 3 years old bec the head grows remarkably during this years. • The eruption of deciduous teeth may vary it can be early as 4 months and much later in some infants but the cut approximates adult head circumference @ 6 years old off period is 13 months. Measured over the glabella and supraorbital ridges anteriorly and part of the occiput which gives the • Any infant whose primary tooth has not erupted by 13 months should be investigated for possible delayed maximum circumference posteriorly (make sure not to eruption of deciduous tooth/teeth. This may be a bone include the ears) or cartilage problem or endocrine problem (in case of A child with small small head - microcephaly indicative congenital hypothyroidism). of a small brain which may lead to cognitive deficits

• Average increase in head circumference: Age

Increase

1st year First 4 months Next 8 months

#”

2nd year

1”

3-5 years

#”

6-20 years 6-10 years 11-15 years 16-20 years

0.5” per 5years

Total

Total of 4” per month $” per month

2” 2” 1”

per year

1.5” 1.5” 0.5” 0.5” 0.5”

• Note that head circumference increases more rapidly during the first 4 months. 2” increase is gained only in 4 months while the other 2” increase is gained in the next 8 months. • Example: 1. By the end of 2 nd year I expect an increase in head circumference of about = 4” +1” = 5” 2. At 5th year we expect an increase in head circumference of: 4” + 1” + 1.5” = 6.5” Therefore, a 5yo child is expected to have a head circumference of: Ideal Hc = Ave Hc + Increase in Hc Ideal Hc = 14” + 6.5” = 20.5” 3. A 20yo Head circumference is expected to be: Ideal Hc = Ave Hc + Increase in Hc Ideal Hc = 14” + 4 +1 +1.5 +1.5 = 18” 3. Quiz: Head circumference at 5 months old: Ideal Hc in inches = 14” + 2” + $” = 16.25” Ideal Hc in cm = 16.25 x 2.54 = 41.28 cm


(above).

Measurement of head circumference.

CHEST CIRCUMFERENCE • Mostly this is not taken routinely. • Measured at mid respiration at the level of xiphoid cartilage or substernal notch • Best measured in recumbent position for infants • No exact value but we expect it to be less than head circumference in early infancy, equal to head circumference in mid infancy, and greater than head circumference in late infancy Early infancy - Chest circum < Head circum Mid Infancy - Chest circum = Head circum Late Infancy - Chest circum > Head circum

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Birth defects are aberrations on infants’ genes, prenatal environment or both.

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Congenital Defects are caused by environmental factors (3%), purely genetic (25%), multifactorial both genetic and environment (25%), and some unknown cause (40%).


-- Oski et. al, 1994

Growth and Development factors affecting prenatal growth • Remember that the embryonic period (3 rd-8th week) is the • What are the factors affecting the prenatal growth? It can most crucial term in prenatal growth. be genetic, environmental, or both. !

Brain dev - Most critical period starts from embryonic period, from week16. Week 20 onwards would be a less critical period. ! Heart dev - critical period also begins at the beginning of embryonic period but ends a little bit earlier (much earlier than the brain) at 8 weeks. The period of vulnerability is from 6 th to 8th weeks. • Cleft lip / palate - usually attributed to a fall during the mother’s pregnancy. But a more logical and medical explanation would be: The period when the palate is developing is from 6 th or 7th - 9th week. Ask the patient for any illness or exposure to radiation or any teratogen during this period bec it may explain the occurrence of cleft palate. • Only 80% of births are normal


I. GENETIC A.Single Gene or Mendelian Disorder " Inheritance of RECESSIVE allele from each parent. Examples are PKU, Tay-sach’s, sickle cell anemia. " Inheritance of DOMINANT allele. Example is Huntington’s disease B.Chromosomal Aberrations " Errors in meiosis - incorrect number or damaged chromosomes in the egg or sperm. " 90% of fertilized egg with chromosomal abnormalities are miscarried; 1/160 newborns. " Examples are Down Syndrome, Klinefelter’s extra X, XYY syndrome, Trisomy X, Turner’s - single X.

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Factors affecting prenatal growth genetic and environmental II. ENVIRONMENTAL FACTORS A. Age of Mother ! The older the mother, the greater is the incidence of anomalies of CNS, Down syndrome, mental subnormality, premature labor, and dizygotic twins. The cut off period is 35 years old. ! ! Risk of having a baby w/ Down Syndrome: Age of mother Under 30 30 35 36 37 38 39 40 42 44 46 48 49

Incidence 1/1000 1/900 1/400 1/300 1/230 1/180 1/135 1/105 1/60 1/35 1/20 1/16 1/12

B. Age of Father ! Advanced paternal age is associated with an increased incidence of achondroplasia, apert’s syndrome, down syndrome, osteogenesis imperfecta, congenital heart disease, and congenital deafness. C. Maternal Stress ! Increase in production of adrenaline, obstructed blood flow, changes in the mother’s body chemistry. ! Emotional state of the mother can affect the pregnancy D. Abnormal Uterine & Placental Conditions ! Placental conditions include bleeding, placenta previa, unusual position of placenta etc. ! Obstruction (caused by ex. myoma) will deprive space & nutrients, and impede the growth of the fetus will lead to: ! Intrauterine growth retardation (IUGR) ! Preterm delivery ! Malformations like talipes, hip dislocation, torticollis, and facial palsy. E. Multiple Pregnancy ! Higher risk of mental retardation, cerebral palsy (CP), and other abnormalities. nd ! The 2 twin (usually smaller and stays a bit longer inside the uterus) is more susceptible to hypoxia and birth trauma. F. Postmaturity ! Placental insufficiency


! ! !

Fetal distress, hypoxia, abn neurological signs Higher morbidity in the first year CP risk increases past the gestational age of 41-42 weeks.

G. Teratogens ! These are substances in the environment that can cause abnormalities durng prenatal priod: 1. Alcohol • Heavy drinkers - 1 in 6 chance of stillbirth and 1 in 2 chance of delivering child with birth defect. • More hazardous do binge drinkers, those who drink early in pregnancy. • Any amount is dangerous. • Fetal Alcohol Syndrom (FAS) - 1/3 of babies born to heavy drinkers - 1/1000 births - TRIAD of: Poor growth, unusual facial characteristics, CNS problems - the first sign of FAS is SEIZURE! This is due to withdrawal (the baby gets a lot of alcohol supply inside the mother’s uterus, upon birth the supply is cut off.). - What can be used to stop the seizure? Give the baby alcohol.  2.Tobacco • Raises carbon monoxide, vasoconstricts blood vessels • May cause premature delivery and low birthweight • 10 or more cigarettes per day cause significant impact on the child’s intellectual performance at age of 4. • Smoking increases risk of cleft lip & palate. • May be a factor in learning disorder and overactivity (ADHD). • Smoking of the father (mother is a passive smoker) - risk of low birthweight.

Fetal Alcohol Syndrome Infant with FAS. Note the unusual facial characteristics.

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...cont. Environmental factors

B. Diseases 1. Rubella # Blindness, deafness, mental retardation and heart defects # Preventable: immunization # Probability of birth defects: 60% 3rd or 4th week after conception 25% 2nd month 8% 3rd month 2. Endocrine Disorders #

Hypothyroidism - Congenital hypothyroidism is characterized by physical, mental retardation. - If hypothyroidism is managed by the 2 nd month of life - absence of birth defects :) - If by 3 months most of the effects of hypothyroidism are already IRREVERSIBLE - A hypothyroid mother will give birth to a hypothyroid infant

#

Diabetes - Hyperglycemic mother will give birth to a hypoglycemic infant . - Why? - When the mother is diabetic, the baby’s glucose level also increases. In order to protect itself, the baby will produce more insulin (pancreas already active) - As the insulin protects the baby from hyperglycemia, it simulates growth hormone so the baby becomes bigger and bigger inside the womb not necessarily because of the glucose levels but because the Insulin which mimics Growth Hormone. - At the end of pregnancy, the baby is larger for it’s gestational age. This is the first index of suspicion for a diabetic mom. - When the large baby is born, the supply of glucose from the mother’s blood is lost so the infant becomes hypoglycemic. In addition, the baby still carries large stores of insulin which is produced by his own pancreas that will soon be metabolized but it takes 2 days to decrease the level of insulin. - 1 episode of hypoglycemia can destroy neurons. This may then lead to permanent mental retardation.


An infant with congenital Rubella.

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Organ Development CNS By Dra. De Guzman

The brain starts to form in embryonic stage. Specifically 16 days post fertilization the brain starts to form. First 27 days are crucial for neural tube closure and formation. The entire pregnancy is a critical period for brain development more so in the earlier months than the later part of pregnancy. I. ETIOLOGY OF HUMAN NERVOUS SYSTEM MALFORMATION

A. TERATOGENS • Fetal malpositioning or crowding • Hyperthermia (it is important to ask the mother if she had fever during pregnancy) • Physical agents in utero • Radiation • Trauma B. INFECTIOUS AGENTS IN THE UTERO • Cytomegalovirus - silent virus • Herpes virus 1 and 2 • Mumps virus ** • Rubella virus ** • Varicella ** • Toxoplasma gondii • Treponema pallidum ** can be prevented through immunization C. MATERNAL METABOLIC DERANGEMENT • Antiepileptic drugs • Anti metabolites • Hypoxia; Carbon monoxide • Cocaine & Ethyl alcohol • Iodine deficiency & Malnutrition • Isotretrinoin & Methyl mercury • Maternal toxin & drug exposure • DM & PKU • Vitamin excessive / deficiency! D. GENETIC CONDITIONS • Autosomal Dominant • Autosomal Recessive • Chromosomal abnormalities

“There are 100 million neurons at birth. 3million base-pairs makeup the genes and DNA in human being. Only a portion of genes are responsible for physical appearance, most are believed to be involved in forming and running the CNS.” - Human Genome Project

II. SIMPLIFIED SCHEME OF BRAIN DEVELOPMENT IN HUMANS Folic acid is important not only during pregnancy but even before pregnancy because folic acid can make sure that the neural tube is going to close. Critical Event

Dev. Window

Neutral tube closure 3-6 wks Dorsal cleft formation

Ex of major human disease

Schizencephaly, Spina Bifida

5-6 wks

Holoprosencephaly

Ventral specification 5-6 wks

Septo optic dysplasia

Neuronal proliferation

8-16 wks

Microcephaly

Neuronal migration 10-15 wks (onset)

Periventricular heterotopia

Neuronal migration 10-20 wks (movt)

Lissencephaly

Cerebellar Development

20-40 wks and beyond

Dandy walker, Joubert’s syndrome

Neuronal differentiation

20-40 wks and beyond

Mental Retardation

Clinical Q: Hc of a 5 year old is 50cm is that ideal for age? Increase in Hc = 4” + 1” + 1.5” = 6.5” x 2.54 = 16.51 cm Ideal Hc of a 5yo = Ave Hc + increase in Hc = 34cm + 16.51cm = 50.51 ~ 50cm Therefore, the 5 yo child has an ideal Hc of 50c m. III. POSTNATAL BRAIN GROWTH

Rapid during infancy and early childhood Gradual increment in mid & late yrs & 1 st decade Very small terminal ! throughout adolescence 1/2 is achieved at the end of 1 st yr; 3/4 by 3yrs 9/10 by 7years • Most crucial during the first 2-3 years of life • • • •

(include the 9mos inside the mom’s womb in counting)

• Relative weight of entire CNS is high in early life: # #

JOUBERT SYNDROME. The disorder is characterized by absence or underdevelopment of the cerebellar vermis and a malformed brain stem


# #

1/4 of total body weight in 2nd fetal life 1/10 @ birth 1/20 @ 5 years 1/50 @ maturity

• 2 critical periods of brain dev: - Embryonic / early fetal period - Late fetal life & infancy

• Brain depends on glucose as only source of energy & requires large supply of O2 for metabolism • Malnutrition during infancy = reduced brain weight = decreased head circum & reduced intelligence • Quality of neural dev is shaped by child’s experiences • Experience strengthens synapses, if not used, it withers away thus, it needs to be stimulated.

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Sensory Development TOUCH First sense to develop • Cheeks - 1st receptive Genitals - 10 weeks Palm - 11 weeks Soles - 12 weeks Abdomen and Buttocks - 17 weeks

• Nakakaramdam ba before birth? YES, they can.

TACTILE SENSATION - Touch and Pain are not well differentiated @ birth - With growth, more receptors are found in the skin - Cephalocaudo progression RESPONSE TO STIMULI • Newborn - Hyperesthesia for 1wk - need for strong stimulus, the infant reacts through general body movements, and Crying possibly reflex withdrawal - During rotation in NICU you’re asked to extract a blood sample from a newborn (2 days old). Would the newborn feel the pain? - YES, strong stimulus (lancet) is needed for them to react. The way they react is through crying & reflex body movements.

• 1-2 months - After 2 months the baby was brought back to you, will the baby remember you/painful stimulus you did? NO. Because they do not have memory yet in this period. - Will the baby feel pain when you repeat the cbc procedure? YES, but there will be:

- More delayed response - Diminution of body movements - Incapable of localizing stimulated part. • 7-9 months - The baby was brought back to you when he’s 7-9mos old. You did extraction again on the right inde x finger. Would that infant be able to feel the extraction? - YES. The infant knows that the pain is somewhere in the upper extremities but doesn’t know what exact area of the body is painful. There will be deliberate withdrawal movements

- Generalized localization of the point of irritation: the infant knows that the irritated part is in the upper extremities but cant tell if right or left. • 12-16 months - Specific localization - Infants carry their hands to the point of stimulation - Rubbing the area or pushing the stimulus away - Eyes may even fix on the area - This time, when you do a repeat cbc, the baby will know that the source of pain is in the right index finger.

SMELL

OLFACTORY SENSATION • Present at birth and develops over time • Only at 2-3 months that infants can distinguish the face of their mother, but earlier than this they recognize their mother through SMELL.


TASTE • Garlic, Curry, Onion, Cumin - Well differentiated by the fetus, well transferred through the amniotic fluid or in breastmilk. - When a pregnant mother eats spicy food, the baby inside the womb becomes restless. • 13 - 15 weeks - Fetus’ taste buds already look like adult’s - Fetal swallowing increases when surrounded by sweet taste and decreases with bitter and sour tastes - We are predestined to be partial for sweet taste - If the mother did not breastfeed, the baby will prefer formula milk that is sweet. - It is easier to introduce solid foods to breastfed babies. Because breastfeeding will let the infant taste / experience a lot more taste and flavors vs formula milk than has only one taste (sweet). • Newborn - Has more taste buds than adult and discriminates tastes particularly sugars. They have the ability to detect sweetness in mother’s milk. MOUTHING - Infants explore the environment through mouthing - 3-4 months & max is until 1yo. (fine in infants only) - Primary circular reaction: moving hands to the mouth and sucking reflex - For 2yo (1.5 to 2): already has the ability to touch, explore through other senses, and they are now more mobile. Thus, mouthing in this age may imply developmental delays and mental retardation.

HEAR AUDITORY SENSATION • Can infants hear upon birth? -- YES • 8 weeks: - Ears begin to form • 18 weeks (4.5 months): - Bones of the inner ears and nerve endings from the brain develops - Fetus can hear the mother’s heartbeat and blood moving through umbilical cord and becomes startled with loud noises. • 24 weeks (6 months): - Structurally complete. • 25 weeks: - Baby can hear mother’s voice (father’s as well), differ in pitch of the voice. • 27 weeks: - Baby can recognize or differentiate voices. - Fetus’ movements or body patterns may change in response to sounds.

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...cont. Hearing

• @ birth: MIDDLE EAR is of adult size - Drum membrane may be smaller & more oblique - External canal is cartilaginous & shorter than adult - Eustachian Tube is shorter & more horizontal. Clinical application: Remember that ETube connects middle ear and nasopharynx. If there is Respiratory Tract Infection, secretions from nasopharynx can easily reach the middle ear resulting to Otitis Media.

• HEARING is primarily reflex until 3-4months: - Startle response - Grimacing - Crying - Eye blinking - Changes in respiratory pattern When a door is slammed in a nursery room, infants are going to respond. They will NOT look for the sound, they will rather just be doing body movements. • 3 months - Localization starts through eye movts or head turning. • 4 months - Searching activities: - Looking - Head turning - Reaching - Ambulation towards sounds Remember : REFLEX-LOCALIZATION-SEARCH • • After end of 1st year - There is refinement of listening skills. • 3 years old - Basic auditory skills are completely mastered. • DISTURBANCES of Hearing: - Decrease in vocalization - Diminished laughter and smiling - Extreme visual attentiveness to movt of the mouth to compensate hearing loss - Speech delay ( remember no stimulation = less output) - Infants can be hearing impaired but can respond to environmental sounds. Remember that pitch & tone of environmental sounds is LOWER than the human voice so envt sounds can be heard easily. Human voice has higher pitch & frequency. Therefore infants can hear & react to sounds in the environment, even if they cannot hear human voice. They cant hear words, so they’ll not be able to speak.

VISION • Last sense to develop • 18 weeks: - retina detect a small amount of light filtering through the mother’s tissues 26 weeks: - Eyes are open and begin to blink • • 33 weeks: - Pupils can now detect light, constrict and dilate - Fetus sees dim shapes


• 37 weeks - Fetus turns towards bright light &

! beats faster.

VISUAL SENSATION AFTER BIRTH • Visual cortex of the occipital lobe has begun differentiation before birth & is complete by 3months • 16 weeks: - Macula & fovea - complete structural differentiation - Myelinization of visual nerve fibers is well advanced • Vision improves dramatically @ 4months postnatal. Infants have better vision at 4 months (highlight in visual development) • 6 years: - Final maturation of the macula VISION • The perception of light, color discrimination and determination of size and shape. • You visited a friend who just gave birth. You looked at the baby in the nursery. Can that newborn baby see you? YES. The infant can see objects (faces) but with hazy borders. • They have preference to oval shaped, moving objects that are 8-12” away from their eyes. - Newborns prefer dark bold colors like black, violet rather the pastel colors like baby pink and baby blue. • @ birth: - Has light perception - Infants are Hyperopic (far sighted) - Respond to a bright object by: 1. Brief fixation of eyes 2. Decreased motor activity 3. Changes in respiration - Moderate Photophobia: Eyes are kept closed, and pupils are miotic but will enlarge in weeks. - Lacrimal glands: " not fully developed, some tearing " Crying reflex not present until 1-2 months " Psychic weeping dev in the middle of 1 st year " Spontaneous canalization at 6-8months. Stimulate the lacrimal glands to hasten canalization " Increased formation of “muta” • 3 months - Recognition of familiar objects (milk bottles) 3-5 months • - Color perception: red, yellow, blue and green • 4 months - Visual acuity of 20/200 - Verydeliberate, coordinated following of moving object 4-5 months • - Visual motor stage - Approaching movements-with the upper extremities

1 1 0 2 , 7 2 e n u J


...cont. Vision

• 5-6 months - Retention of visual images • 6months - Accommodation-convergence reflex - Stranger Anxiety or “nangingilala” When you bring babies to the clinic, they start crying. - Binocularity - synchronous movement of the eyes - Problem: Squint or “Banlag” - common in babies below 6 months old -- the extraocular muscles are still weak so the eyes deviate. - @ 6 months the extraocular muscles are stronger thus eye movement can be directed to one focal point. • 6-7 months - Deliberate reaching & Prehensile stage • 1 year: - Visual acuity of 20/100 • 2 years - Esotropia (normal) or convergence first appear - Visual acuity of 20/40 • 3 years - Can appraise size and location of an object • 4-5 years: - VA of 20/20 (Perfect vision @ 4yo)



• 6-7 years: - Depth perception VISUAL DISTURBANCES: 1. Absence of Protective Blinking 2. Absence of Pupillary Reflex 3. Failure to follow moving object 4. Strabismus (Squint)

Which of the 5 se nses is/are not prese nt at birth? ANSWER: NONE. All are present at birt h.

Organ Development CVS • 2 periods: (a) very slow increment in the first 4months AOG, then (b) steady more rapid increment. • Little change in the ! size for the 4-6 weeks after birth, then steady growth • 9-16 years: 2nd period of rapid growth. • X-ray picture of the heart doesn’t differ from the outline of an adult’s by end the of 2 nd and 3rd year. • All ECG components found in an adult are present already as early as about 5 weeks. • 11-12 weeks: - Fetal ECG can be recorded or 6 weeks earlier than ausculatory perception. • Remember that Left ventricle is bigger than RV, but there is Right Ventricular preponderance or Right Axis Deviation several months after births. Bigger RV than LV is normal for a young heart then, • Left sided growth and considerable involution of the muscle mass on the right. • Adult relationships by age 7 with the LEFT wall 2-3x thicker than the right.


• Size of the heart is best determined by Cardiothoracic Index (CT index): - Get the Chest X-ray - Measure the size of the ! in widest diameter - Measure the chest at it’s largest diameter (diaphragm area) - Size of the Heart ÷ size of Thorax = CT index • CT index may be above 0.5 in the first 3 years of life but should be less than 0.5 subsequently (after 3 yrs). • Why? Because the thorax is increasing in size greater/ faster than the heart. • Closure of: • Ductus Venosus (carries blood from placenta to the vena cava) immediately after birth. • Ductus arteriosus • Foramen ovale • Most infants show a left to right shunt during the first 24 hours and gradually decreases to a small percentage by 8 days. • Early or late cord clumping -> changes in the circulatory dynamins # Late cord clumping - Dynamics of the newborn - Expansion of the blood volume - Increase heart size - Increase systolic blood pressure - Increase respiratory rate - Pulmonary rales & transient cyanosis # Early -> anemia • Fetal Heart Rate $ Usually between 130-160 $ Quite variable $ Fully cooperative, quite, and emotionally stable patient $ Valid variables can be obtained when the child is fully cooperative, quiet, and not emotionally stimulated. $ Ave Heart Rate is inversely proportional with age ( !Age, " HR) $

Average Heart Rate Age

Heart Rate

Birth

140

1sr month

130

6-12 months

130

1-2 years

110

2-4 years

105

6-10 years

95

10-14 years

85

14-18 years

82

1 1 0 2 , 6 y l u J


...cont. CVS

• Heart rates variable during infancy ! Sinus Arrhythmia is considered to be physiologic in infancy or childhood. Irregular Heart Rate. ! BP varies from day to day ! BP " directly proportional ! BP increases with age due to increased vascular resistance. • Normal Blood Pressure - ( !Age, !BP) Age

BP

Day 1

78/42

1 month

86/54

6 months

90/60

1 year

96/65

2 years

99/65

4 years

99/65

6 years

100/60

10 years

110/60

16 years

120/65

• Heart Sounds: ! Higher pitch ! Shorter duration ! Greater intensity • Innocents systolic murmurs • Vibratory • Pulmonic ejection • Venous hum

Organ Development RESPIRATORY SYSTEM • • • •

Movement of the fetal chest, 40-70 per minute is present at about 70% of the time during last half of gestation. Detected sporadically as early as 13 weeks of gestation Reflex gasping as early as 11-12 weeks. Diminished resp movement with HYPOXIA or HYPOGLYCEMIA.

Anatomically: • right primary bronchus is larger than the left and at a more acute angle. If there is a foreign body that is taken in by a child, it is easier to look for it in the right primary bronchus.

• Dimension of larynx at birth is ! that of an adult Infants are • Cavity is short and funnel shaped in infancy ( prone to difficulty of breathing & respiratory infection ) • There is rapid growth until 2-3 years then, slower increment until puberty. • Trachea of a newborn is 4 cm long , or ! the adult length • Narrow lumen of respiratory tracts and shorter airways: any kind of resp infection will bring about accumulation of secretions that result to difficulty in respiration # Wheezes - common cold # Stridor - harsh vibrating sound that is caused by obstruction in airways; maybe due to secretions


• Airways grow predominantly antenatally but alveoli develop after birth, increase in number until 8yrs old; and in size until chest wall ceases growing as an adult. • Airways dev - prenatal; Alveolar dev - postnatal • Little change in the topography of the lungs, fissure or pleura from infancy to maturity. • ANOXIA - most important stimulus to the onset of breathing. Sets in when the cord is cut! • FALL IN pH - the true stimulus to breathing. - due to accumulation of acid metabolites. • To know if the baby was born dead or alive: - Submerge the lungs in a basin of water. If it floats, it means the baby was born alive since the lungs were aerated when baby had it’s first breathe. If it doesn’t float, this means no breathing occurred and the infant was born dead. • Respiration in infants is largely diaphragmatic until the 5th-7th years of life ( abdomen rising&falling w/each breathe). • Rate & depth of breathing extremely variable in infancy. • Breathe sounds in children: (due to thinner chest wall !) " Loud " Harsh " Seem near to the ears • Breathing Rates: - The younger the age, the faster breathing rate - Impt thing is to remember cut off upper limit LISTEN for examples! - In new born the average bpm is 60-70 (more realistically is 60 bpm) - At 10 years breathing rate is almost like adult’s - Remember cut off values (upper limit) Age

Breathing Rate

Newborn

30-80 bpm

1 year

20-40 bpm

2 years

20-30 bpm

5 years

20-25 bpm

10 years

17-22 bpm

20 years

15-20 bpm

Conditions not seen in normal newborns: • Apnea & Periodic Breathing - both are cessation of breathing. • APNEA - More than 20 seconds or longer - More serious etiologies; more pathologic - Due to prematurity, endocrine imbalance & inborn errors of metabolism - Can be due to problem w/over all dev of the brain. • PERIODIC BREATHING - Less than 20 seconds - Common & expected in some infants - Not so serious, brought about by immaturity of CNS. - Higher centers will dev towards end of first year, so it cant regulate yet bodily fxns as well as it should. • OBLIGATORY NOSE BREATHERS - Infants do not know yet how to breath through mouth when they have colds or congested nose, they can be cyanotic. - Infants can easily experience respiratory distress even just simple colds

1 1 0 2 , 6 y l u J


• REASONS OF ABDOMINAL PROTUBERANCE IN TODDLERS:

Organ Development GI SYSTEM • MOUTH EPSTEIN PEARLS - Translucent pearl white round areas over the posterior portion of hard palate ( sago-like ). - These are embryonic remnants in infants - Not pathologic and will disappear in 3-4 days PETECHIAE - Capillaries that burst at the level of the mouth. - This may be due to trauma during vaginal delivery.

•

•

Drooling th

• Drooling increases w/ eruption of first teeth (6 mo) • Prominent by about the 3 rd month which is the start of maturation of the salivary glands • Prepares the infant for maceration of food • A protruding tongue may accentuate the condition • This is fine only until 18th month • After 18 mos, drooling accompanies intellectual disability or lower cognitive function • Sign of cerebral palsy due to spasticity and weakness of oral motor muscles. • ESOPHAGUS $ GASTROESOPHAGEAL REFLUX • Regurgitation • Common among children less than 1 year old • Laxity of gastroesophageal sphincter( physiologic ) • A full infant will experience distention of stomach, the fluid (milk) has nowhere to go, it will go up to esophagus then to the mouth • “lungad ” or curdled milk - is normal for infants until 1 yo however, if this occur frequently and in voluminous amount, the infant will develop esophangitis ( the curdled milk is acidified ). • GASTRIC CAPACITY $ Growth of stomach is most rapid between birth and 3rd month of life. Age

$ $

Gastric capacity

Birth

30-90 ml (1-3 oz)

1 month

90-150 ml (3-4 oz)

1 year

210-360 ml

2 years

500 ml

Later childhood

750-900 ml

•

• •

•

1. Lordotic posture - they tend to straighten up their bodies in preschool. 2. Laxity of abdominal muscles - cannot contain Organs that are growing dramatically. 3. Abdominal cavity is small relative to the size of the organs GAS BUBBLES # Visualized in the stomach with 1 st cry # 2nd hour - ileum # 3rd-4th hour - rectum # If none is present in the sigmoid by 24 hours, it would mean that there is an Obstruction. OBSTRUCTION is indicated by (sx/sy): - Absence of meconium or 1st stool - non passage - Distended abdomen - Vomiting Abdominal X-RAY is the 1 st diagnostic test (fastest and simplest) to check for gas bubbles, for location of gas bubbles in the first 24 hours. At birth - lower intestine is filled with meconium Normal infant passes out meconium by 24 hours 69% of infants passes out meconium by 12 hours 94% of infants passes out meconium by 24hours. 6% of infants passes out meconium w/in 24-48 hrs. MECONIUM - first stool - Amniotic fluid debris, bacteria have not yet acted on this fecal material - Pasty, viscid, sticky, doesn’t smell so bad, black. - Don’t let an infant leave the hospital unless it has its first urine and meconium pass out (no passing out of meconium indicates intestinal obstruction). How does meconium gets into the lungs? - If meconium is passed prematurely (before birth), fetus exp distress will prematurely pass out the meconium. Meconium mixes with amniotic fluid ( remember that amniotic fluid is swallowed & passed out). So if meconium has mixed w/amniotic fluid and swallowed, it’s not a problem in the utero but once the infant is born & takes first breathe of air, the meconium may go into airways then down to lungs and stay there # infants develops ball valve phenomenon (air can go in but have difficulty getting out) so the normal respiratory cycle is disturbed. Meconium aspiration pneumonia.

• Stools are most numerous between 3-6 days with a mean average of 5/24 hours

A regular feeding bottle = 8 oz or 240 ml Remember that 1oz = 30 ml

• LIVER % At birth the liver forms 4% of the body weight % Liver weighs 4x of it’s birthweight on Puberty. % Palpable liver edge is very common throughout infancy and early childhood


Epstien Pearls

1 1 0 2 , 6 y l u J


• TRANSITIONAL STOOL • Passed from 4 th to 7th day • Stools of breastfed babies are: homogenous, sour, pasty and yellow • Stools of formula fed babies are: thin, sour, slimy, brown to green. • By age 2, stools are more formed and darker. • Breastfed babies pass out more stools than for mula fed babies. Formula milk is more concentrated and harder to digest. • By age 2, stools are more formed and darker.

Meconium

Organ Development URINARY SYSTEM • Growth of kidneys slow down in early prenatal life • Lowered GFR during the first 9 months of life ! We

don’t want to over burden our kidneys, it doesn’t work as effectively as kidneys of adults. So: 1. Caution: give babies dose medicine appropriate for their weight & age 2. Breastfeed, if not, choose a formula milk that is appropriate for age. Protein content varies. 3. No added salt to solid foods of babies • The ECF volume of the newborn infant is higher (nearly double) that of adult

• ECF if newborns is 40% of the bodywt & in adult it is 20% of bodywt • infants - prone to dehydration & overhydration than adult because of high volume of ECF in infants • Infants exchange fluid at a much faster rate.

• Adult = 2000ml/day (5% of total body fluid) Infant = 600-700 ml/day (20% of total body fluid) • Who exchanges more amount of volume of fluid per day? ADULT Who exchanges greater% of total body fluid per day? INFANT • Daily excretion of water by the GIT averages 200-500ml for an infant and 100-300ml for an adult • Neonate Physiologic Immaturity:

1. If GFR is only 30-50% than that of adult, it has not reached normal adult levels until late into the 1 st yr. 2. Decreased ability to excrete sodium load 3. Decreased ability to excrete water load 4. Inability to concentrate urine • Preterm low birthweight infants - irreversible water loss is inversely proportional to gestational age.


• Small amounts of urine are usually found in the bladder at birth the Newborns may not void urine for 12-24 hours or longer • Newborns should not be discharged until they void the first urine in the first 12-24 hours.

Organ Development GENITAL ORGANS TESTIS • Relative weight of testis is same in adult’s • 4th - 7th fetal (before birth) month: - testis lie at the site of the future abdominal ring. th 8 fetal month: • - Testis attached to the fundus of the scrotum • @ BIRTH: - 96% of FULLY MATURE male infants have their testis fully descended in the scrotum. - 70% are descended in PREMATURE infants - The longer the fetus stays in utero, more time for the testis to descend into scrotum - Premature infants are more prone to undescended testis. - In both term and preterm infants 50% of the undescended gonads did come down into the scrotum by the end of the 1 st month of life. • End of 1 YEAR: - Incidence of undescended tetis is <1% OVARIES " Grows rapidly during early post natal life " 6 months - doubling of weight of the ovaries 12-15 years: " - Another doubling of weight " There is 90% decrease in ova from birth to maturity st "Uterus involutes in the 1 week of life, with regain of birthweight at 10-11 years. Remember: Genital organs will have 2 nd phase of growth during puberty.

BASIC PEDIATRICS

8 1 y l u J

Prepared

a l u c i

July 18 2011

s e v i t c e O b j

h e v

  t e g e s

N U T R I T I O N

u t c e l

n t n u t r i e

evaluate To be able to evaluate a patient using basic tools for nutritional assessment.

identify To be able to identify patients who need more specific and detailed nutritional assessment.

Nutrition is an input to & foundation to health & dev . Nutrient is a substance that can be metabolized to give energy & build tissue.

s e s o p r P u

Mineral or substance in food of the food itself that is needed to live and grow. Better nutrition will lead to:

1. Better immune system ! In children we are very much concerned on the immune status especially for newborns " preterm #. Preterm infants are considered to be immunocompromised because the immune system at this stage is not yet fully dev. Remember that there is 2 types of immunity: " a # T!cell which is cellular, and " b # B!cell which is acquired and

involves antibodies. Newborns are not yet exposed to foreign bodies allergens therefore they have not yet develop acquired 16 | prepared by cmgt

immunity. Thus, there is increased occurrence of cough&colds in the first 5years " childhood # for about 3 or 5 times a year. 2.Children learns better 3.Children are stronger 4. More productive 5.Better quality of life

by

charlene tingzon:)

%

Helps the clinician de te rm in e if patient’s nutritional needs are being met by their normal diet.

%

When used appropriately, used in diagnosis of nutrition related disease and in determining the nutritional need.

BASIC PEDIATRICS # 18 JULY 2011

Types of Nutritional Assessment % Baseline

or Screening Nutritional Assessment ! Comparing individual child to population norms ! Each population has di$ erent norms ! Philippines has its own population norms ! Ex. Newborns babies of western pop vs asian pop: Western = taller, heavier " IBW of 3.5 kg # Asians = shorter, lighter " IBW of 2.5!3 kg # ! Asians are considered malnourished if western standard is used. % Specific Nutritional Assessment ! Specific problem, deficient, and manifestation

I. 



  

• To be done to all patients • History: ! Direct questions about current and past health ! Will give an idea of nutritional status of the patient ! Determine the typical dietary intake • Physical examination growth and development including sexual maturation • Anthropometric measurements ! Weight, height, head circumference ! BMI • To determine whether normal eating habits are developing. WEIGHT " Simple reproducible growth parameter " reproducible if standard scale is used # " Serve as an index of ACUTE nutritional status " Can be weight loss or weight gain Ex: 1. In acute glomerulonephritis, decrease in GFR will results to edema which accounts to the 5& increase in body weight. 2. In acute diarrhea, there is passing out of loose stools thus there is 5&!10& or 20& decrease in body weight. Accurate age, sex and reference standards are " necessary for evaluation. " Evaluated in 3 ways: ! Weight for Age ! Weight for Height ! BMI Weight below __ percentile ! weight deficit " ! undernutrition th " Weight above 85 percentile ! weight excess ! overnutrition, obesity 1.


"

Recent change in weight " loss/gain #

"

Common weighing apparatus: ! Standing, Bathroom scale, Infant scale

2. HEIGHT/LENGTH cted " A better criterion of growth since this is una $e by excess fat or fluid. " It takes a longer time for height/length to be a $ ected " Can be used to assess growth failure and CHRONIC UNDERNUTRITION ! causes delay in height for age. " Younger than 2 years old should be measure recumbent measurements to the nearest 0.5cm " NOTE: to negate the e$ ect of Lordotic stand of the patient which makes them appear shorter #. " Use infantometer " Height is for 2 years old & up " Length is for 2 years old & below " HEIGHT ASSESSMENT: a # Growth charts ! not very accurate ! used to compare child’s ht & wt to a standard range. ! Very dependent on the person who sets up the growth chart. b # Stature Meter ! predetermined spot on the wall ! Positioning is important ! Occiput, shoulder blades, hip and heel should touch the vertical wall. ! The person measuring the patient’s height should be at the eye level of the patient. ! If the eye level is UP, measure height will be less ! If the eye level is LOWER, measured height will be increased. c # Percentile Chart ! height for age chart. ! how the pt is growing in time ! Each individual dev his own percentile canal ! Ex: 3& means that 97& of the population is taller than you. ! Deep/plateau growth " exaggerated!lose ht/child is nor growing #


Types of Nutritional Assessment 3. HEAD CIRCUMFERENCE " Influenced by nutritional status until 36 months " Indicator of brain growth " Land marks: upper eyelids " supraorbital ridge #, most prominent part of the occiput the glabella

II.    • WHO NEEDS TO BE ASSESSED?

Patient Characteristics: ! Not following growth channels ! Inadequate food intake may be dictated by culture ! ! Inappropriate food choices ! ! Excess nutrient losses ! Those who su " er # om GI problems lik$

4. BMI " Better reflect the amount of body fat compared with amount of muscle or bone " NORMAL VALUES =  "

gastroenteritis, diarrhea, GERD, vomiting, congenital abnormality like volvulus, intestinal obstruction % short bowel syndrome, w/colostomy, imperforate anus.

      !

"

"

BMI PERCENTILE # Used for classification of adiposity in childhood given the changing adiposity in this period. # Adiposity rises in the 1st year of life. # Reaches a nadir " lowest # around 5!6 years of age # Then will increase again " due to regained appetite # throughout childhood known as adiposity rebound: ! If this comes before 5!6 yo there is high risk for obesity ! Normal BMI b/w 5 th!84th percentile for age # Female in adolescent period ! ! eating # If you ambulate ! lose baby fat # At 3!4 yo they loose more fat because they become “picky eaters” Other Methods to Determine Adiposity: ! Skin fold thickness ! Mid!upper arm circumference " MUAC #

* cross sectional mid arm muscle & fat areas ! Ultrasound ! CT scan, MRI ! Waist to hip ratio

BODY MASS INDEX " BMI # • Z scores " up to 3 yo # ! +1 SD ! overweight +2 SD ! obese -1 SD ! undernourished th • Percentiles ! > 85 %ile ! overweight - > 97th %ile ! obese - < 15th %ile ! undernourished


• PURPOSE:

Determine if nutrient deficiencies are present ! Ex: specific nutrient deficiencies like Vit.C deficiency & Det. possible causes of abnormal nutrient status & Help direct nutritional therapy &

1. HISTORY

Current & past medical or surgical conditions which may a $e ct the patient’s nutritional status ! Serve as an index of ACUTE nutritional status ! Psychosocial inquiry which suggests behavioral issues a $e cting nutrient intake " eg. children are given condensed milk % high sugar conten( # ! Developmental milestones !

2. DIET

Record all food intake, portion, size, manner of preparation for 3!7 days ! Take note of: Variety, Quantity, Quality ! Nutritional Hx should be assessed esp. in pediatrics ! Ex. What type of feeding?, How he/she is fed?, How many !

Done based on medical condition

* higher ration = obes" "

Congenital oral abnormality ! Most common is cle & lip / palate: can’t be breastfed and/or bottle% fed due to decreased sucking ability. Sma ' y done. # equent feeding is usua '

bottles of milk?, What type of water?, storage of bottle?


Classification of Malnutrition ...cont. Specific nut. Assessent

U nder nut ri t ion

3. PHYSICAL EXAMINATION (PE)

Anthropometric measurements ! Mid! upper arm circumference " MUAC # ! Used to determine cross sectional arm muscle & fat areas in conjunction with skin fold thickness. ! Skin fold Thickness ! Estimation of total body fat ! When used in conjugate with weight!for!height, it can determine chronic undernutrition ! Physical appearance in relation to malnutrition & agra # ' certain deficiency " eg. Kwashiorkor, Pe # ! More extensive examination " eg. skin, hair, nails etc. ! Look for specific signs of nutritional deficiencies: !

a # Alternating dark&light bands of hair ! kwashiorkor b # Bow !legged & demineralized bone! Vit. D deficiency c # " night vision ! Vit. A deficiency

Height for Age - index of cumulative effects of undernutrition - chronic or Long term Weight for Age -reflects combined effects of both recent & long term levels of nutrition. Weight for Height -reflects recent nutritional experiences

1. Gom ! Cla " ification

! Child’s weight is compared to that of a normal child " 50th percentile # of the same age. ! It is useful for population screening and public

health evaluation ! Percent of reference weight!for!age



 

  

       

c ) y y c c r n n e i e o i k c c r fi o e fi i e h d d s a D A t i t w i K V V ) ) ) a b c

a # A 4 year old weighs 12 kg: Ideal weight of a 4 year old Weight " kg # = age in years x 2 + 8 4years x 2 + 8 = 16 kg " 12kg ÷ 16kg # x 100 = 75"

Buphthalmos & phthisis

b # A 4 year old weighs 12 kg ! su$ ered from post strep glomerulonephritis.

b)

a)

12kg X 15& of baseline weight " 12kg X 15&# + 12kg = 1.8 + 12kg = 13.8 " 13.8 ÷ IBW of 16 # X 100 = 86"

MALNUTRITION

' " 12kg x 15& + 12 # ÷ 16 ( x 100 = 86"

Measurement of Classification of Malnutrition Mild

% ideal body wt

Moderate

Severe

80-90

70-79

< 70

Usual body wt

90-95

80-89

< 80

Albumin (g/dL)

2.8-3.5

2.1-2.7

< 2.1

Transferrin (mg/dL)

150-200

100-149

< 100

Total Lymphocyte Count (per µL)

1200-2000

800-1199

< 800


! Disadvantage: not able to classify if the change in

weight is due to EDEMA. % of reference wt for age

Interpretation

90-110%

Normal

75-89%

Grade I - mild

60-74%

II - moderate

< 60%

III - severe


Classification of Malnutrition

2.We # come Cla " ification

! evaluates the child for EDEMA & with Gomez

classification system ! Evaluates child whether child has edema or none. Wt for age (Gomez)

w/ edema

w/o edema

60-80%

Kwashiorkor

undernutrition

< 60%

Marasmic- kwashiorkor

marasmus

3. Waterlow Cla " ification

! Chronic malnutrition results in stunting. ! Malnutrition also a $e cts the child’s body proportion

eventually resulting in body wasting. ! With weight and height discrepancies = chronic %IBW = Actual Weight_

X 100

Ideal Wt for Ht

* det if there is wasting %IH =

Actual Weight

X 100

Ideal Ht for Age

How do we know how much nutrient a child needs? 1. Estimated Average Requirement (EAR) - Amount of nutrient that results in some

predetermined physiologic endpoint ! Endpoint is usually maintenance of satisfactory rates of growth & dev and/or prevention of specific nutritional deficiencies. ! Experimental in nature

* det if there is stunting

Wasting Weight-for-height

Stunting Height-for-age

Normal

> 90

> 95

Mild

80-90

90-95

Moderate

70-80

85-90

Severe

< 70

< 85

4. Diagno $i c Inv %t igation ! CBC with di$ erential count ! Total Lymphocyte Count WBC x &Lymphocytes • Mild malnutrition ! 1500 • Moderate malnutrition ! 800!1200 • Severe malnutrition ! <800 ! Pre!albumin, retinol!binding protein

2. Recommended Dietary Allowance (RDA) ! Intake deemed to meet the “requirement” by the

most healthy member of a population ! If the EAR of a specific nutrient is known ! the RDA for that nutrient usually is set at the mean requirement " the EAR # plus 2SD " standard deviation #. ! Mean requirement for many nutrient is not known thus RDA is di)cult to establish 3. Dietary Reference Index (DRI) ! Includes RDAs for those nutrients for which an

EAR has been established & for which an RDA can reliably be established as well as other requirements 4. Other Reference Intakes: a. Adequate Intake (AI) ! Used when RDA cant be established ! Observed or approximated daily intake of that

nutrient by a group of healthy individual ! Based on the intake of apparently “normal” infants and/or children 20 | prepared by cmgt


Nutritional Needs ...cont. Other RI - adequate intake

! Ave intake = amount of breast milk ! For the first 4!6 months ! it is the average amount

of nutrient an exclusively breastfed infant takes ! 7!12 months ! it is the amount of nutrient in the average volume of human milk + ave amt of complementary foods consumed by healthy normally growing 7!12 months infants. b. Tolerable Upper Intake Level (UL) ! Highest daily intake of a specific nutrient that is

likely to pose no risk ! Avoid excessive nutrients c. Philippine Recommended Energy and Nutrient Intake (Phil. RENI) ! Considered adequate for the maintenance of health

and well being of nearly all healthy persons in the population

Nutritional Needs "

Unique for infants up to Adolescents ! Rapid increase in weight and height/length ! Higher metabolic & nutrient turn over rates ! Marked developmental changes in organ function " sti ! continuously developing # and composition eg. Ave. height @ birth = 50 cm Ave. height @ 1 yr = 75 cm Ave. caloric intake of an adult = 1500 !1800 ! 1st spurt of growth ! newborn / infancy ! 2nd spurt of growth ! adolescent age group ! ! height of 2!3” during summer

"

In neonates and infants: nutritional intake is complicated by: ! Lack of Teeth ! Immature digestive & metabolic processes ! Dependent on caregivers " the debilitated & bedridden too # #

"

If the caregiver choose to dilute the milk or put som$ iodized salt in it, the infant cant do anything about it.

0!6 months old infant ! Estimated energy requirement is expressed per unit of body weight ! Requires 3x than adult


! Sources of energy:

CHO Fats CHON

5g /kg /day 1 g /kg /day 1.5 g /kg /day

FATTY ACIDS ! Very important in infants ! ARA & DHA are lower in formula fed infants than

breastfed infants. ! Essential FA ! Saturated: acetic, butyric, capric, lauric, palmic, stearic, arachidonic, lignoceric ! Unsaturated: crotonic, palmitoleic, oleic, linoleic, arachidonic, nervonic

LIPIDS ! Essential FA = linoleic and !!Linolenic acid " unsaturated # ARA # ! Produces: Arachidonic acid " Decosahexanoic Acid " DHA #

Long Chain Polyuns aturated Fatt y Acids (LC-PUFA) ! Better visual and cognitive dev in breastfed infants ! Reflects presence of LC !PUFA in breast milk ! Most relevant LC!PUFA are: ARA & DHA ! DHA accounts for 40& content of retinal

photoreceptor membranes; prevalent FAs in the CNS.

PROTEIN ! Require higher proportion of amnoacids than adult

ESSENTIAL AMINO ACIDS ! 10 amino acids ! Arginine, histidine, isoleucine, leucine, lysine,

methionine, phenylalanine, threonine, tryptophan, and valine. ! Main sources: meat, dairy products, cereal grains " wheatm corn, rice etc # and legumes " beans, nuts # ! Should be provided daily " NOT stored in the body #


Nutritional Needs         

Hepatic cystathionase

Methioinine Cysteine ! modified form of cysteine = N !acetyl!cysteine " NAC # breaks down mucus & detoxify hard coated substances ! Soy Protein ! methionine insu)cient ! used for babies w/ cow milk protein allergies ! Supplement w/ formulas fortified w/ methionine Phenylalanine hydroxylase

Phenylalanine Tyrosine ! At or near adult levels @ birth ! No problem if no phenylalanine deficiencies Tyrosine ! Epinephrine, norepinephrine, serotonin,& dopamine ! ! cardiac contraction, ! !rate, vasoconstriction, will all lead to ! Blood Pressure. ! Melanin ! Making regular hormones ! Low levels associated with: & Depression & Low BP & Low Body temperature & Underactive thyroid ! High quality & easy digestability of human milk compensate for any quantitative deficiency • 1st 6 months of life ! Babies survive with breast milk only even with

supplementation • Casein ! Babies would have curdled milk " regurgitate milk in semi!solid for # ! Used in formula milk before ! Di)cult to digest • Whey-based ! Human milk ! Easy to digest 

ELECTROLYTES, VITAMINS & MINERALS ! Electrolyte intake for both breast milk & formula

approximate with the DRIs for each

IRON ! Born with su)cient stores for 4 to 6 months of life 22 | prepared by cmgt

! Babies undergo physiologic anemia due to

increased need for iron as they grown and due to expansion of extracellular compartments w/in the intravascular space ! give Iron supplements after 4months of life ! Human milk contains less iron but iron deficiency is less common in breast fed infants ! Iron in breast milk is better absorbed in the duodenum

Vitamin Deficiency ! Rare if protein intake is su )cient

Vitamin D ! Supplemented in both breastfed & formula fed infants ! Breastfed infants are less susceptible to develop vitamin d deficiency ! Activated in the skin by exposure to sunlight # go to the liver # hydroxycalciferol # kidney # di! hydroxycalciferol # intestine # Ca absorption

4 Com mon Pandemic Nutrient Deficiency (PND) • • • •

Niacin ! Vit C ! Thiamine ! Vit D !

pellagra scurvy beri beri rickets

Vitamin K ! Routinely admin. @birth at 1mg i.m. Single dose ! @ birth the intestinal tract of an infant is sterile, no bacteria in it & the first stool than will pass out, known as meconium, " debris of ingested materials like mucosa, amniotic fluid that has been swallowed by the baby # is also sterile. ! Colonization of bacteria in the intestinal tract will only begin until the First feed. ! given initially bec the neonate is Vit K deficient ! Vit K is important for coagulation ! Deficiency may be present in infants & children receiving prolonged antibiotics and those with fat malabsorption

WATER ! ! ! !

Water requirement of a neonate is quite high Normal infant’s requirement= 75!100 ml/kg/24hours A 3kg infant = 300ml/day Infants have higher obligatory renal, pulmonary, and dermal water loses as well as higher over all metabolic rate

BASIC PEDIATRICS # 01 AUG 2011

Needs • Feeding NEWBORNS / NEONATES ! Increased sensible and insensible water loss Sensible water loss ! measured by urine output. Insensible water loss ! cannot be measured ! sweat, respiration, stool

Normal respiratory rate = normal 40 !60/ minute can go as high as 60/minute. ! They have greater surface area, ! dermal water losses ! Neonates pass out stool as much as 8x/day which contributes to higher insensible water loss ! Strong gastrocolic reflex ! pass out stools every after eating ! Increased amount of water required. !

6-12 MONTHS ! Exclusive breastfeeding ! 1 oz formula milk = 20 calories ! Caloric Intake should be about 100!110 calories/day A 3kg baby has a total caloric intake of: 110calories/day X 3k = 330calories/day How many oz of milk will the 3kg baby needs to consume/day? 330calories/oz ÷ 20 = 16.5 oz How many times the baby should be fed? = 6-8x/day If you need 16.5oz/day, and will feed the baby 8x/ day, you need around 2 oz of milk/feed.

Same for breast milk, if you can quantitate the amount of breast milk per oz that will provide you a minimum amount of 20 calories/day ! Adequate Intake for most nutrients cited for this age group reflects the amount of that nutrient on the average volume of human milk consumed. ! For a 6 !12 month old, the nutrient requirement would be the average amount of milk intake of a 6!12mo old infant PLUS the amount of the ave intake complementary foods. " based on a breastfed infant # ! In the first 6 mos of life the advocacy is breastfeeding, and in 6 !12 mos old we now introduce complementary foods. Weaning should be done gradually. !

1 YEAR OLD & UP ! The child’s rate of growth slows down and the nutrient needs for growth consequently, will decrease ! In the 1st yr, there is rapid ! in growth & dev. E.g.Weight ! 2x the birthwt @ 4 mos, 3x the birthwt by 1 year 23 | prepared by cmgt

But after 1 yr, there is still an increase in growth but in a slower rate. ! The rates of growth remain appreciable ! @ 1 yr, there are significant milestones that ! the demand for nutrients. Activity increases: eg. The baby can now walk/run, exploring greater area. ! Nutrient needs after the 1st year of life are only minimally less than those during the 1st year of life. ! Still, there are Increased nutrient & caloric requirement but not as high as less than 1 year old. !

AFTER 2 YEARS OF AGE ! Eats the same food as the rest of the family ! Milk is not taken out in the diet but it is NO LONGER the main source of energy & nut. ! So there is a problem when the baby’s main food is still milk at 2 yo. ! Food guide pyramid as modified for this age group ! 2!3 years old need the same servings of each food group as that of 4!6 years old children, but size is 2/3 the size of serving for 4 !6yo. COW’S MILK

• 3xDRIofProtein • 2xDRIforSodium • 2/3ofDRIofIron • 1/3DRIofLinoleicAcid(DHA,ARA) • Dangeroustoinfant -“dangerousratherthanbeneficialtotheinfant”

Feeding When is the right time to feed an infant after birth? • Right after birth • " if the infant is medically well # • @ birth all things needed for feeding are present in a term infant • Swallowing & sucking reflexes are present already at birth • Digestive enzymes are present • Before the breastfeeding advocacy, we wait for 4 hours before feeding " not app now # • Unang Yakap Program of DOH Right frequency of feeding in the 1 st month of life? • 6!8x for the first mo of life. This will gradually decrease as child grows older however, portion of feeding will increase.


Feeding GUIDELINES FOR FEEDING " 6!12 months #: # Complementary foods are introduced in a stepwise manner # Start giving complementary foods in liquefied / milk% lik$

! May be caused by insu)cient amount of food or

fluid ! Diets high in protein, low in bulk ! Enemas & suppositories are only temporary measures. ! Can be a manifestation of congenital problem like Hirschsprung's disease.

consistency then as you progress feeding lessen the water content. Introduce one new food at a time # Additional new food should be introduced at a space of 3!4 days # Introduction of egg !containing products to the diet is delayed " after 12 months old # ! We do not want to sensitize the baby ! May miss out vaccines because vaccines are usually egg yolk based " measles, MRR vaccines #. ! Mostly commonly caused by supplementation #

" 5 # COLIC ! Symptom complex of paroxysmal pain and severe

crying usually in late afternoons or early evenings that persist for hours. ! Occurs in children less than 3 months of age ! Consider a di$ erential Dx acute abdomen " rule out the possibility of acute abdomen #

FEEDING PROBLEMS

Food Pyramid • Plate

" 1 # UNDERFEEDING

Decreased intake of food caused by: ! Frequency, mechanics of feeding ! Size of the holes of mother’s nipples ! Adequacy of eructation of air " burping before and a & er feeding #. Babies should be burped midway and a& er

' ' ' '

feeding ! Abnormal mother!infant bonding ! Systemic disease " eg. sepsis # Failure to take in su)cient amount of food

When the baby is agitated or forced fed " 2 # OVERFEEDING ! Leads to regurgitation & vomiting " even diarrhea # ! Abdominal distention ! Overweight & obesity ! Most commonly caused by supplementation " 3 # REGURGITATION & VOMITING ! Regurgitation ! within certain limits. Normal in the

first several months of life. Passing out of gastric contents that is passive. Regurgitation beyond 4 mos of life must be investigated. ! Vomiting ! may occurs in normal infants but a search for other causes must be done. More serious. Passing out of gastric contents that is forceful. " 4 # CONSTIPATION ! Hard dry stools which are di)cult to pass ! Practically unknown in breastfed infants and rare in

formula fed infants receiving an adequate intake


'

Grains, Cereals, pasta. Food guide pyramid becomes a PLATE Plate ! simple way of putting up a message we need to have a balance diet. My Plate: with some same messages ! Eat variety of foods ! Eat less of some foods and more of others ! Features 4 sections: 1. Vegetables 2. Fruits 3. Grains 4. Protein ! Plus a side order of dairy. BIG message: PLATE DIVISION ! Fruits & veg take up half of the plate w/ vegetable portion being a little bigger than the fruit section. ! Aims to discourage super big portions which cause weight gain and obesity.


Breastfeeding ! ! ! !

Exclusive in the first 6 months of life No other food or fluid is given to the infant Even water should not be given. MOTHER & BABY FRIENDLY HOSPITAL INITIATIVE " MBPHI #

! Main strategy of DOH to transform all hospitals

with maternity and newborn services into facilities which fully protect, promote, and support breastfeeding and rooming !in practices. !Hospitals can not be given a license if it do not comply with MBPHI #

LEGAL MANDATES

# Water Requirement of Neonates is high

• 75 ! 100 cc/kg/day • 140 ! 150 cc/kg/day between 3 to 6 mos of life

! RA 7600 ! " the Rooming %in & Breastfeeding Act of 1992 #. ! EO 51 of 1086 ! " the Milk Cod $ # #

GUIDELINES TO A SUCCESSFUL BREASTFEEDING:

1 # Have a written breastfeeding policy that is routinely communicated to all healthcare sta $. 2 # Train all healthcare sta $ in skills necessary to implement this policy 3 # Inform all the pregnant women about the benefits and management of breastfeeding. 4 #Help mothers initiate breastfeeding within half an hour of birth 5 # Show mothers how to breastfeed, & how to maintain lactation even if they should be separated from their infants. 6 #Give newborn infants NO food or drink other than breast!milk unless medically indicated. 7 # Practice rooming "in " allow mothers & infants to remain together # 24 hours a day 8 # Encourage breastfeeding on demand. 9 #Give NO artificial teats or pacifiers " also called dummies or soothers # to breastfeeding infants 10 #Foster the establishment of breastfeeding support groups & refer mothers to them on discharge from the hospital or clinic.

!

Exclusively breastfed infants " 0!6 mos # do not need additional water because:

1. Breast milk water content is more than enough. • • • • • • • • •

Breast!milk is 88& water, also consist of: Nutrient proteins Non!protein nitrogen containing compounds Lipids Oligosaccharides Vitamins Minerals Hormones Enzymes, growth factors & protective agents it has 10& solids for energy & growth

2. Low solute conten# • Breast!milk has low solute content • No need for extra water to flush out solutes !

BREAST!MILK STOOL is soft and minimal in amount. Constipation is not a problem for breastfed babies.

!

BREAST!MILK IS A LIVE SOLUTION ! It constantly changes. ! Milk content is changed by: ! Start age of lactation a& er giving birth " Colostrum immediately ! Baby’s gestational period " erent kind " A mother of a preterm baby has di ' of breast % milk compared to a mother of a fu

term baby ! Mother’s age ! Time of feed



Breastfeeding # ADVANTAGES OF

BREASTFEEDING:

• Breast Milk: ! Perfect nutrients ! Easily digested & e )ciently used/absorbed ! Protection against infection ! Costless • Breast Feeding: ! Helps mother!infant bonding ! Promotes uterine contractions ! Delays pregnancy " form of contraception # ! Protects the mother’s health # BREAST!MILK CONTAINS: (

Secretory Ig A % prevent microorganisms # om adhering to the intestinal

mucosa & also contains substances that inhibit growth of viruses, thus lower cases of diarrhea, otits media, pneumonia, bacteria, and meningitis (

(

Milk macrophages % Lactoferrin, Lysozyme, Complement. Bifidus Factor % Good bacteria % Promotes good, protective intestinal bacteria ' i % Bifidobacteria and Lactobaci % Breastfed infants hav$ lower stool pH thought to

contribute to the favorable intestinal flora of infants ' i, FEWER E.coli % MORE bifidobacteria & lactobaci Oligosaccharides ( Milk lipids ( Human milk contains bile salt! stimulated lipase, which kills Giardia lambia & Entamoeba histolytica ( Transfer of tuberculin responsiveness by breast milk suggests passive transfer of T!cell immunity (

# DISADVANTAGES OF

BREASTFEEDING: • Transmission of disease: ! HIV ! Cytomegalovirus " CMV # ! Human T cell Lymphotropic Virus type 1 ! Rubella virus if mother is + to HepaB antigen sh$ ! Hepatitis B virus ! ' breastfeed bec virus is known to transfer through can sti breastmilk only in very minimal amount & nowadays w$

! Allergens to which infant is sensitized can be

conveyed in the milk ! Mastitis ! Septic active TB, typhoid fever, breast CA,

malaria ! Substance abuse ! Severe neurosis ad psychosis • Maternal Linkage of Drugs: ! Anti!thyroid medications ! Lithium ! anticancer agents ! Isoniazid ! Recreational drugs ! Phenindione ! Dx radiopharmaceuticals ! Sulfonamide ! Metronidazole ! Chloramphenicol ! Athraquinone!derivative laxatives # Reflexes

or Behavioral Pattern that facilitate breastfeeding present at birth 1. Rooting reflex 2. Sucking reflex 3. Swallowing reflex !* ' i depend on gestational age. No

problem with term infants but if preterm infants ) <34weeks old, swa ' owing reflex may not be dev yet 4. Satiety reflexes # STORED BREAST MILK

! General Breast!milk storage guidelines: a. At room temperature " <25º Celsius # for 4!8 hrs b. At the back of the refrigerator for 3!8 days c. At the back of the freezer up to 3 months " refs

that temp can go lower that 0ºC but accdg to Nelson it is for 1 month only # Remember: if you freeze the breast!milk, do not heat it bec proteins will be denatured. # EXPRESSED BREAST MILK

! Normal breast!milk may vary in color:

Bluish Yellowish Brownish

have vaccines and immunoglobulins. If the vaccine & IG is administered before the 12th hour of life, this can o" er protection & breastfeeding can be continued. ) ! Herpes simplex virus

• Contraindications to breastfeeding: ! HIV infection 26 | prepared by cmgt

                                   


Breastfeeding # BREASTFEEDING

TECHNIQUES

2.

INVERTED NIPPLE ! to manage flat & inverted nipples: MANAGEMENT OF PLAT & INVERTED NIPPLES • Antenatal treatment is probably not helpful • Build the mother’s confidence • Explain that the infant suckles from the breast not from the nipple • Encourage her to give plenty of skin to skin contact, and let her baby explore her breasts

" Signs

• Help her position the baby • Help her try different positions to hold her baby • Help her to make her nipple stand out more before a feed.

of good attachment

! Infant’s chin should touch the breast ! Infant’s mouth should be wide open ! Infant’s lower lip should be turned outward ! There should be more areola in the baby’s mouth

TO SHAPE HER BREASTS... $ The mother supports it from underneath with her fingers and presses the top of her breasts gently with thumb $ She should be careful not to hold her breast too near the nipple

3.

SORE NIPPLE ! seen during first 10 days post partum, usually peaks between 3 rd to 6th day LOOK FOR A CAUSE • Check attachment • Examine breasts • Check baby for tongue tie

" Good Positioning

GIVE APPROPRIATE TREATMENT • Build the mother’s confidence • Improve attachment and continue breastfeeding • Reduce engorgement-feed frequently

! Infant’s head & body should be straight ! Infant’s head & body should be facing the breast ! Infant’s body should be close to the mother ! Mothers should be supporting the infant’s entire

body

3. EDEMA ! women who receive excessive intravenous fluids throughout labor may develop edema. ! IMPACT

!

How will you know if the baby is getting enough breast milk? It can’t be measured. Look for signs:

COMMON BREASTFEEDING PROBLEMS DURING THE FIRST FEW DAYS OF INFANT’S LIFE

If the baby is still hungry, the baby will CRY. If the baby is satisfied, fall asleep ! Weight loss of more than 7 & from birthweight may be an indicator of breastfeeding di )culties & requires evaluation of the feeding process for the first 10 days. ! Passing small amount of urine. !

1. ENGORGEMENT ! under the influence of hormones, the breast increase milk production from 36!96 hrs " Riordan, 2005 #. CAUSES: • Plenty of milk • Delayed start of breastfeeding • Poor attachment to breast • Infrequent removal of milk • Restriction of length of feeds


PREVENTION: • Start breastfeeding soof after delivery • Ensure good attachment • Encourage unrestricted breastfeeding.

OF THESE PROBLEMS ON INFANTS

!

OTHER ANATOMICAL CONDITIONS THAT PREVENT THE CHILD FROM BREASTFEEDING WELL ! Tongue tie

BASIC PEDIATRICS

n t h s 0 !6 m o

COMPLEMENTARY FEEDING

! Target Age is 6mos ! 2 yrs

Why start at 6 months?

!

                                   

Bec it has been shown that:

1. The spitting out reflex " tongue thrust reflex #, th$ ' spit out anything child wi you put in his tongu$ , starts to disappear @ 4months, completely disappears at 6months.

          

2. Most of problems about food borne pathogens starts upon introduction of new solid foods

rd s a w n o s 6 m o n t h

3. If eating solid foods starts early, you introduce sensitization.

- Breastmilk alone is not sufficient to cover all the nut requirements for the growth of the child

4. Amylase becomes functionally mature @ 6mos. Amylase is needed in digestion & absorption of complex carbohydrates.

complementary feeding

5. If eating solids start early, intake of breast milk is limited. The infant is not able to optimize e $ ect of breast milk.

- The process of starting other foods and liquids and are given along with breast milk to provide for the child’s increase in nutrient requirements. - In contrast to weaning - Weaning: • Complete cessation of breastfeeding • Stop breastfeeding and give other food • No longer advocated - DICTUM: If you start complementary feeding, continue breastfeeding. - if for some reason, breastfeeding is not possible then continue the formula milk feeding

% There are studies which say that the first 4 reasons, except 5, are not that important. " #5 is a su # cient

reason not to start giving complementary food early.

% If complementary foods ar $ given earlier than 6 mos: "

Breast milk is not optimized " Atropic sensitization of the child " more food a " ergies ar #

manifested # " ! exposure to foodborne

pathogens

Guidelines in complementary feeding 1. Practice exclusive breastfeeding from birth up to 6 months and introduce complementary foods @ 6 months while continuing breastfeeding.

It has been shown that breastmilk is protective against GI infection &, boost immune sys. Longer period of breastfeeding, child has better cognitive dev, enhanced motor dev, EQ is better. a.Iron ! if there is normal iron prenatal stores, the fetus has enough iron to sustain him for 6!9 months ! Reserves become lower if mother is anemic & if the baby is immature. ! Iron transfer occurs on 3rd trimester, the less time you spend on the 3 rd trim, the lower the chance of having enough iron stores ! For Low birthweight prematures ! start supplementation of Iron as early as 8 weeks. ! Even in normal ind " even if mother’s prenatal iron stores are normal #, the infant’s level of iron stores start to drop at 2nd to 3rd month. ! 3 doses: 1mg/kg/day ! supplemental; once a day 6mg/kg/day ! therapeutic dose for w/ IDA 3mg/kg/day ! midway, give to kids with low stores but not yet anemic, given TIB " to replenish stores # ! The higher the dose of iron, the more

erratic the absorption if given @ a single dose " thats why you have to divide it into 3 doses # ! Ferrous sulfate ! given on an empty stomach,

with vitamin C ! Iron Polymaltose complex ! may give regardless of meal. b.Zinc ! Important mineral ; "morbidity&mortality from infectious disease ! Treatment for diarrhea: • " morbidity • Shorten course • Enhance reepitheliazation of intestinalvilli ! Available in low amounts in breast milk compared to cow’s milk but the bioavailability of iron and zinc in breast milk is better c.Maternal diet ! Mother is advised to take in all nutritious foods ! Should the mother stop giving certain foods if the

child is showing signs of allergies?

! Check first. Let the child eat certain foods if

signs appear then stop giving THAT food. 28 | prepared by cmgt


Complementary Feeding d.Vitamin D ! Sunshine ! free & unlimited source of vitamin D ! RDA = 20 minutes exposure to sunlight " 7!8am # e.Exclusive breastfeeding promotes: ! Promotes weight loss of the mother ! Prolongs post gestational amenorrhea " natural form of contraception # ! Infant & maternal bonding ! Growth and development ! GI development 2. Continue frequent, per demand breastfeeding until 2 years of age and beyond. a # High fat content for the absorption of fat soluble vitamins " ! amounts of good fats for vit ADEK absorption, for brain dev, vision # b # Substantial source of micronutrients c # During illness, it prevents dehydration and provides nutrition d # Longer duration of breastfeeding. • Increase linear growth • Reduced risk for childhood chronic illnesses • Reduce obesity • Improve cognitive outcome 3. Practice responsive feeding a # 3 types of feeding practices Controlling ! parent controls Laissez Faire ! child controls Responsive ! recommended, interaction between baby and caregiver b # Infants feed directly while young kids are as sisted c # You must be sensitive to the satiety and hunger checkpoint of the child # Mom looks for visual clues from child if he wants more # Kids are fed face to face " spoon # # Let older children eat by themselves too d # Feed the child slowly " Eating should be an enjoyable experience " Do not force the child to eat " Less distraction as much as possible e # Pay attention to the mood of the child f # Eye to eye contact is important g # Less destruction " dont let them eat in front of tv # h # Be creative 4. Safe preparation & storage of complementary feeding ! Good hand washing before & after meals, good washing of food and utensils ! Serve thoroughly cooked food ! Store in clean, CLEAR, covered container ! Cook what is enough, avoid leftovers " milieu for food borne pathogens # 5. Amount of complementary food provided. ! As the child grows, increase the amount of food 29 | prepared by cmgt

6. Food consistency • 6 mos ! pureed, mashed, semi !solid • 8 mos ! finger foods " avoid irregularly shaped # • 12 mos ! same as the family • 10 mos ! critical time for “lumpy” food ! if later than this the child wi ' have feeding problem. ex: Nagsisipsip lang ng pagkain bec ' owing they are not used in chewing & swa

solid foods # 1 new

food should be introduced at a time & addt’l new foods should be spaced by 3!5days # Start with foods w/ single ingredients first # At 10th month the child must learn how to chew 7. Meal frequency and Energy density ! 2!3 x / day " 6!8 mos " 9!11 mos ! 3!4 x / day " 12!24 mos ! 3!4 x / day with 1!2 nutritious snack at + least 2!3 hours before meal " not chocolates, not jun foods, instead give a bread with spread or # uits ) 6!8 mos ! start once a day @ 6 th month, 2x/day @ 7th and 3x/day @ 8 th month. " Introduce new food " solids # every 3!5 days " Correct the mistake that feeding should start with cereals, potatoes, fruits, beef " last #. " Instead: put iron sources in the first stages of feeding: start with cereals vegetables & meat as iron source, fruits. " Malunggay is a very rich source of Iron " At

8. Nutrient content of the complementary ! Variety of foods ! Protein source everyday: meat, poultry, fish, eggs ! Vitamin A rich fruits & vegetables ! Avoid low nutrient drinks ! Zesto, iced tea, co$ ee ! ! calories, "nutrients ! Keep juices to not more than 240ml/da y ! Make sure fruit juices are freshly squeezed ! Most fruit juices contain FRUCTOSE ! causes obesity, induces high insulin levels. ! Technically fructose is like vodka w/o the fizz ! Egg white ! richest source of protein. Best way of cooking is soft boiled. 9. Feeding during and after illness • Give more food during recovery period • Give what the child wants to eat 10.Use of fortified complementary food & vitamin! mineral supplementation for the infant supplementation # Medicinal drops, syrup, capsule " iron,zinc # # Sprinkles mixed with complement foods # Maternal diet # Fat based spread


Feeding Problems FORTIFIED ! putting vitamins on a food which do not

usually contain it. SUPPLEMENTATION ! giving the vitamins or mineral in the form of capsules, drops, syrups. •

Feeding problems during 1st year 1.UNDERNUTRITION • Failure to take in su)cient amount of food " even when it is o$ ered # • Clinical manifestations: ! Restlessness, crying often, constipation, poor sleep, irritability ! Failure to gain weight, slow weight gain and even actual weight loss. • Look into: ! Frequency of feeding ! Mechanics of feeding ' How is the child being fed? ' Feeding technique ' If Breastfeeding ! Check the procedure ! Check mother’s nipple ! Check the “Latching” " eructation of air # ' If Bottle fed ! The kind of formula milk ! Check the rubber nipple ! Check how often ! Check the bore ' Check if child is being burped ! Before transferring from one breast to the next, let the child burp wait at least for 30mins ' When feeding position the child with head & neck elevated ! Abnormal mother!infant bonding ! Systemic diseases ! Child abuse / neglect • Treatment: $ Increase nutrient intake, amount & frequency, fortified foods $ Correct vitamin/mineral deficiency $ Educate the caregiver 2.OVERFEEDING • Clinical manifestations: ! Regurgitation and vomiting ! Weight gain: # High FAT diet ' Delays gastric emptying ' Abdominal distention & discomfort 30 | prepared by cmgt

Excessive weight gain High CARBOHYDRATE diet # ' Causes undue fermentation in the intestine ' Abdominal distention & flatulence ' Rapid weight gain Normal gastric emptying time is 2 hours ! time when food in the stomach empties into the intestine 0!3 months ! 25cc/kg ! gastric capacity " persist at around 4 months # " 3kg child = 75cc gastric capacity # Breast milk ! 1.5 ! 2 hours mas matagal pag cow’s milk ! 2 hours '

• • •

3.REGURGITATION & VOMITING Regurgitation • Return of small amount of swallowed food during or shortly after feeding • E$ ortless, natural in occurrence • Normal during 1st year IF does not occur every after each feeding • Burp the baby for 20!30mins, put child down with head&neck/back elevated. Never on supine flat, bec it is only until 18 months that the lower gastroesophageal sphincter is not that mature, milk goes back, go to lungs # can lead to aspiration Vomiting • More complete emptying of the stomach, often occurring some time after feeding • Forceful • Should always be investigated since vomiting is never normal, so it is usually considered pathologic, unless proven otherwise. • Treatment: $ Adequate burping during and after meal $ Gentle handling $ Avoid emotional conflict during feeding $ Right Lateral Decubitus for as short period of time immediately after feeding to promote gastric empt $ Head higher than the body to avoid gastroesophageal reflux $ Do not put the child in a reverse supine or prone position for a long period time ! SIDS 4.LOOSE DIARRHEAL STOOLS • Frequent passage of loose stools • Consider the consistency but not the frequency " stools of breastfed are never hard. # • Breastfed stool " softer and more loose # VS Formula ! fed stools • Diarrhea should be considered infectious disease unless proven otherwise. • Caused by: ! over feeding ! Too high sugar in artificial foods


Feeding Problems ...cont. Loose diarrheal stools

! Other causes: food reaction, excessive juice

consumption, medications, malabsorption, contaminated food. • Proper food preparation & storage • CDC and AAP for Diarrhea Prevention 1. Breastfed infant should continue to breastfeeding on demand 2. Complementary feeding 6 months w/ breastfeeding, formula fed infants should be fed usual amount of infant formula immediately follow rehydration " if indicated # 3. Low lactate or lactate free formula milk is not necessary 4.Infant formula, should be diluted during the disease 5. Use of soy !based formula is not necessary 6.Simple sugars should be avoided too! 7. Infants feeding should continue to receive the usual diet during diarrhea 8. Infant in complementary feeding should continue breast feeding 9.Withholding food and BRAT diet " Banana, Rice, apple sauce, tea # is NOT recommended. 5.CONSTIPATION & Hard, dry stools which are di)cult to pass & It should be sausage shaped " smooth # & Consistency is the basis of diagnosis not the frequency & True constipation is rare in breastfed infants with adequate amount of breast milk. & Enemas and suppositories are only temporary. & Causes: ! Dietary influences $ Inadequate breast milk, infant formula, complementary food, fluid intake $ Improper dilution of infant formula $ Early introduction of complementary foods $ Excessive cow’s milk in older infants $ High protein, low bulk diet ! Abnormal anatomy or neurologic function of the digestive tract $ Tight spastic anal sphincter $ Aganglionic megacolon ! Medications $ Iron, calcium ! Stool withholding due to rectal irritation $ Thermometers etc !

6.COLIC Paroxysmal abdominal pain & severe crying usually in the late afternoons & early evenings Lasts for several hours until exhausted or relieved by bowel movement or flatus or burp Normal for 2!6 weeks until 3 months Associated with hunger, swallowed air, overfeeding, milk allergy, increase carbohydrate, sorbitol Rule out: intussusceptions, strangulated hernia, Treatment: • Hold infant upright/prone • Heated pad/water bottle Prevention: # Hypoallergenic maternal diet # Hypoallergenic milk formula # If child is allergic to cow’s milk give extensively hydrolyzed milk # Improved feeding techniques # Burping # Avoid under or over feeding 7.DENTAL CARIES • Number of teeth = Age in months ! 6 • 3 variables in the formation of dental caries: % Susceptible teeth % Streptococcus mutans ! mouth bacteria % Fermentable carbohydrate ! sugars, starches • Source of periapical abscess • Can lead to meningitis • Infectious disease • S. mutans adhere at the base of teeth to form plaque • Oral prophylaxis every 6!12 mos • Prevention: ! Proper feeding practices ! brush teeth every after meal # ! 1st dental check up ! when the 1 st tooth erupts # ! Appropriate fluoride intake " best applied topically ! Regular dental evaluation & care ! Oral risk assessment by 6 months ! 1st dental check up @ 12 months ! W/significant risk must be evaluated 6 !12mos • How much tooth paste do we need? pea !size for adults and 1/4 pea !size for children

Insu)cient hydration

1 ! hardest ! small pebble!like stool " goat droplet # 6 ! diarrheal consistency & 3 and 4 ! ideal consistency & &


 


Feeding Problems SCU !

Feeding problems during 2nd year 1.REDUCED FOOD INTAKE • Number 1 problem of parents “ mahinang kumai ,” • @ 2nd yr of life caloric requirement also decreases • Weight gain " : 0!6 months ! 600g/month 6!12 months ! 500g/month 2 !6 years ! 2kilos/year • Rate of growth decreases & the child’s intake is also expected to decrease or fails to increase • NOT unusual; avoid force!feeds

SEVERE CHILDHOOD UNDERNUTRITION (SCU) •

•

MARASMUS ! Non edematous SCU w/ severe wasting ! Results from decrease in energy " CHO # intake or inadequate intake of both energy and protein ! Old man faci $, listlessness, emancipation ! Fail to gain weight, irritability ! Loss of skin turgor, wrinkled skin, loss of subcutaneous fat " first area to loose subcutaneous fat is in the buttocks # ! Constipation and starvation ! Diarrhea ! frequent small stool with mucus ! Hypothermia, bradycardia, hypotonia

2.SELF SELECTION OF DIET • Eating habits&patterns develop in the first 2 yrs of life and unfortunately, they will carry this all throughout their lives • Likes and dislikes become apparent • They become “picky eaters” esp in 2nd yr of life 3.SELF FEEDING BY INFANTS • Infants should be allowed to eat by themselves as soon as they seem physically to do so. 4.BASIC DAILY DIET • Parents should be given basic daily balanced diet!plan for the child that provides appropriate & su)cient micro and macronutrients • Balance out @ the end of the week

KWASHIORKOR ! African term for middle child ! Edematous SCU ! Inadequate protein intake ! Lethargy, apathy, irritability, vomiting, diarrhea, anorexia, flabby subcutaneous tissue, hepatomegaly ! Edema masks the failure to gain weight ! Flaky paint dermatitis in unexposed areas of skin ! Flag sign ! in the hair thin sparse hair ! Stupor, coma, death

5.EATING HABITS • Best taught by example • Feeding di)culties arise from ! Excessive parental insistence on eating ! Parental & child anxiety ! Undue meal time stress ! Too much confusion on meal time ! Insu)cient time for eating ! Food dislikes of family members ! Poorly prepared or unattractive food 6.SNACKS BETWEEN MEALS • Not enough to interfere intake of meals and should be nutritious

B.

7.VEGETARIAN FAMILY • Give vitamin B12 supplement  • Malunggay contains 3x protein as that of beef  • Pakbet ! complete with nutrients


PRIMARY malnutrition ! from inadequate food intake/supply SECONDARY malnutrition ! problem is in the patient ! results from increased nutrient needs, decreased nutrient absorption and/or increase of nutrient losses.

   A.


SCU Obesity !

•

•

PATHOPHYSIOLOGY of SCU & Adaptive response to inadequate energy and/or protein intake ) activity and expenditure decreases ) mobilization of fat stores to meet energy requirement ) decrease fat stores ) protein catabolism.

Body Mass Index Classification of Adults

TREATMENT of SCU & Initial or stabilization Phase ! Lasts for 1!7 days ! Oral rehydration; if severe ! IV ! Antibiotic therapy ! Oral feeding " F75 " 75 kcal # #High frequency, low volume #12 feedings/24 hours #80!100 kcal/kg/day " Refeeding syndrome &

&

Rehabilitation Phase ! 2!6 weeks ! Continued Antibiotic therapy " F 100 diet " 100 kcal # #LOW frequency, HIGH volume #6!8 feedings/24 hours ! Start Iron therapy ! interferes w/ action of antibiotics Follow up Phase ! 7!26 weeks ! Feeding for catch up growth ! Emotional and sensory stimulation - ! “free!feeding” ! Feeding as ad libitu ! Parental education is crucial

                                        

Overweight & Obesity

• Based on the calculation of BMI • BMI = kg / m* ! Most reliable method to determined between healthy and unhealthy adiposity ! Consider raw values in adults, percentile chart in children • Adiposity rebound ! Increase adiposity at 1st year, decrease at 5!6 years " lowest point at 6yo #, and increase again. ! Earlier adiposity rebound = ! chance of obesity


BMI (kg/m! )

Weight status

< 18.5

Underweight

18.5 - 24.9

Normal weight

25 - 29.9

Over weight

30 - 34.9

Obese

35 - 39.9

Moderately obese

40 - 49.9

Morbid obesity

% 50

Super Morbid obesity

BMIClassification of Children & Adolescents (Nelson) BMI percentile for age

<

5th

5th -

percentile

84th percentile

85th -

94th percentile

% 95th percentile

Weight status

Underweight Normal weight At risk for overweight Overweight

New classification BMI percentile for age

<

5th

5th -

percentile

84th percentile

Weight status

Underweight Normal weight

85th -

90th percentile

At risk for overweight

90th -

94th percentile

Overweight

th

! 95

percentile

Obese

• Predictors of overweight & obesity ( High birthweight " #1 predictor # caused by gestational DM or maternal obesity ( Strongest predictor for a high birthweight is the amount of weight gain during pregnancy ( As your weight goes near your double digit age, higher tendencies to remain overweight. ( Parental obesity: 2x risk of adult obesity and among children <10 yo • Pathogenesis of Obesity # Dysregulation of caloric intake&energy expenditure # Environmental changes Causes of obesity # Hormonal or genetics PATHOGENESIS 

                                                                                                                                                         


Overweight & Obesity • Comorbidities of obesity Type 2 DM ! insulin resistance Hypercholesterolemia Children w/BMI > 85th percentile have higher Hypertriglyceridemia chance to dev these Hypertension Metabolic Syndrome may result from obesity ! Glucose intolerance, Hypertension, abdominal central obesity Higher risk to dev Diabetes ! " female: waist line closer to 30; males: waist line closer to 35 # Asthma Sleep apnea $ snore loudly at night, wake up in midnight and

& &

&

!

&

overweight adolescents & 10 & of those who are just over weight ! Musculoskeletal problems " orthopedic #

• Evaluation of obesity ' History ' Physical findings ! Appropriately sized BP cu$ ! 2/3 of the arm, 1” above antecubital area ! Acanthosis nigricans ! 90& of type 2 DM, velvety brown to black hyperpigmentation of skin folds. ! Tanner staging " premature adrenarche # !

Hirsutism, male pattern baldness, severe acne ! POS

• Lab screening for obesity ! read Nelson

        

• Treatment of Obesity & Treatment goals vary depending on the age of the child and severity of complications & Weight maintenance is more important than weight loss $ in the absence of comorbidities and BMI less than 40 ! & Slow weight loss " 1 lb or 0.5 lb / week # & Initial goal is to loose 10 & of weight, maintain for 6 months then aim for another 10 & weight loss & Substantial lifestyle change ! most e$ ective ! Diet & exercise 34 | prepared by cmgt

Physician, dietician, psychologist, exercise specialist

Dietary counseling • Limit sweetened beverage " 4!6 oz/day # • 1!6 yo = 4!6 oz fruit juice /day • 7!18 yo = + 7!18 oz fruit juice/day Nutritional Plan ! Based on glycemic index ! Glycemic index ! how much insulin response does the food elicit, the higher the glycemic !

sleep during the day !

Polycystic ovary Syndrome $% /acne & irregular menses ! Psychosocial disorder Non alcoholic fatty liver disease $ 25& of very

Medication & surgery O)ce!based management ! Anticipatory guidelines ! Yearly BMI calculations ! Education " ! physical activity " 60mins/day is enough # " " sedentary activities whole family # " Promote healthy lifestyle " Multidisciplinary approach

index the more you should avoid that food. !

Fruit w/highest glycemic index is watermelon  Tra )cLight or Stop Light Diet ! Limits calories, more good nutrients & Physical Activity ! < 2 yo = NO tv/ computer ! 2 ! 8 yo = <2 hours screen time/day & Medication ! Reserved for those w/ severe medical complications " eg Orlistat # not recommended for kids & Bariatric surgery ! Only for children with BMI >40, obesity with medical complication, or after a failed 6 month multidisciplinary weight management ! Gastric staples ! Roux !en! y ! adjustable gastric bands &

MyPyramid


Vitamins • Note the di " erence between doses in measles & diarrhea

• Fat soluble Vitamins: Vitamins A, D, E, K

Vitamin A Deficiency

• Fat soluble, we cannot syn, need to get from the diet • We need 10g of fat to absorb vitamin A • Mx of deficiency: probs in maintenance of epithelial fxn • Dry, scaly, hyperkeratotic skin patches on arms, legs, shoulders, buttocks " Hyperkeratosis pilaris ! “chicken skin” # • Probs in reticular fxn of GI ! prolonged diarrhea • Poor over all growth, diarrhea, susceptibility to infection, anemia, mental retardation, including increased intracranial pressure. • Faulty epiphyseal bone formation, defective tooth enamel " bone and teeth defects go hand in hand # • SIGNS: ! NYCTALOPIA ! night blindness, earliest sign Delayed dark adaptation due to absence absence of rhodopsin Photophobia ! ! Keratinization of cornea * Xeropthalmia * infections * Lymphocyte infiltration * wrinkled cornea * Keratomalacia " IRREVERSIBLE # * Blindness. ! Conjunctival keratinization + plaque formation " Bitot’s spot # + conjunctival xerosis + Lacrimal gland keratinizes

Hypervitaminos & A

! Toxicity with chronic daily intake of 15,000ug " adults # and 6,000ug " children # ! SYMPTOMS of acute Hypervitaminosis A " CNS Mx: Nausea, vomiting, drowsiness, diplopia,

papilledema, cranial nerve palsies, pseudotumor cerebri " space occupying but there is no real tumor; symptoms of mass lesion w/o mass # " Congenital malformations " Carotenemia ! too much of carotene rich foods. yellow/orange skin pigment but does NOT involve ' owing of sclera i , the sclera " vs jaundice : there is ye jaundic$ # Carrots, squash, papaya ! SYMPTOMS of subacute !chronic HA:

• Include skin Mx. • Irritability, vomiting, anorexia • Dry, itchy, desquamation of palms & soles, seborrheic dermatitis, fissuring of mouth corners, alopecia , stupor, hepatoslenomegaly, hyperostosis of bones ! TREATMENT: ! stop intake of foods ! in vit A

' iamine Deficiency (B1)

Manifestations are generally neurologic ! Hoarseness or Aphonia ! characteristic sign due to paralysis of laryngeal nerve ! Peripheral neuritis, decrease DTRs, tenderness and cramping of leg muscles, pins & needles sensation. ! loss of vibratory sense " late manifestatio, # ! Ptosis, optic nerve atrophy is common ! Muscle atrophy ! ! ICP, meningismus " rigidity without meningitis #, coma ! Beri beri: !Deficiency state • Wet " undernourished, edematous # • Dry " Flabby, without edema # ! Both: ! DOB ! Tachycardia ! Common COD: cardiac involvement # death ! TREATMENT ! 50mg for mom; 10mg for child ! If there are cardiac manifestations: do IM !

 

• DIAGNOSIS ! mainly clinical • PREVENTION ! meet the RDA, enough fats • TREATMENT ! 1 IU ! 0.3 " g retinol ! daily 1500 " g supplementation for latent vitamin A deficiency ! Xeropthalmia take 1500" g/kg orally for 5 days then followed by 7500" g IM • 80& of vitamin A is absorbed with 10g of fat • In viral " ie measles # infections: 1500!3000ug  <1yo = 100 ooo units  >1yo = 200 000 units • Diarrhea: give vit A for re!epithelialization of GI tract eg. Children w/ diarrhea for 14 days

<6 mo = 50 000 units  6!12 mo = 100 000 units = 200 000 units  >1 yo 


Single dose


Vitamins • Dermatitis occurs in the areas that are exposed to sun " main irritation # • Versus kwashiorkor ! where it is n the unexposed areas • Desquamation, erythema, scaling and keratosis of sun! exposed areas • Painful bec nerve endings are exposed & skin cracks # Cassal’s necklace " neck # # Stocking & gloves ! in hands/arms and legs

Riboflavin (B2) Deficiency $ Inadequate intake is the

most common cause $ Faulty absorption in patients with Biliar y atresia, Hepatitis, and if taking drugs that get metabolized in the liver " probenecid, phenothiazines, OCTs, anticonvulsants ) $ Manifestations are mainly oral 1. Cheilosis ! perleche; thinning of lips & lacerations of angles 2. Glossitis ! occurs before perleche, papilla is gone or flattened. 3. Seborrheic dermatitis 4.Keratoconjunctivitis $ Prevention

! Meet RDA ! This is in the food that we eat, so deficiency can be

prevented as long as the child eats a lot of foods rich in vitamins " vegetables etc. # $ TREATMENT ! riboflavin

3!10mg/kilo/day ! 2mg IM aoa as 3x/day if no response $ Remember that there is no vitamin B1, B2, B6 sold separately, so we give Vit B complex

     (   (  (       "        (      

• DIAGNOSIS ! clinical; classic triad + ! corn intake • TREATMENT ! Supplement diet with niacin 50 !300mg/day ! 100mg IV in severe cases or poor GI absorption ! Avoid sun exposure, put soothing application

Py ( doxine (B6) • Most common drug associated with B6 deficiency INH has B6 " also in phenobarbital, anticonvulsants, OTCs # • Risk of deficiency in drug therapy and dialysis • Clinical Manifestations: ! Convulsions, peripheral neuritis,dermatitis, & anemia • TREATMENT: ! 100 mg pyridoxine for convulsions ! Patients with retractable seizures " always having seizures #, look into possibility of b6 deficiency ! ISONIAZID ! always with B6 incorporated in it bec it causes vit B6 deficiency

Biotin (B7) ! Avidin

! biotin agonist

Biotin deficiency seen in patients with prolonged ingestion of raw egg whites " rich in avidin # ! Avidin is a biotin agonist, it attaches to biotin receptors, the body feels that there is biotin when in fact there is none. ! Clinical manifestations ! Dermatitis ! Conjunctivitis ! Alopecia ! CNS abnormalities !

Niacin (B3) Deficiency

• Pellagra • A$ ects all body tissues • Problem occurs where corn is the major foodstu$ • Corn is LOW in TRYPTOPHAN, which is one precursor of NIACIN • Classic triad: D, Diarrhea Dementia # Early: anorexia, weakness, burning sensation, numbness of extremities, dizziness # Late: depression, disorientation, insomnia, delirium Dermatitis " sudden or insidious # • Stomatitis and glosstitis


Folate (B9)

" Risk of deficiency is ! during periods of rapid growth

or

! cellular metabolism " pregnancy & adolescence # " Drugs: ! dose of NSAIDs, methrotrexate, phenobarbital

" Pts with G6PD must be supplemented with Folic Acid #

" Inborn errors of metabolism " Maternal

supplementation of 400mg FA prevents Spina Bifida and Anencephaly


Vitamins

Cyanocobalamin (B12)

• Main food is from animal sources. • Vegan diet must be supplemented with Vitamin B12 ! Prone to pernicious/megaloblastic anemia

Ascorbic Acid (Vitamin C) Most popular and most abused vitamins ! SCURVY deficient state. ! Poor wound healing ! Ecchymosis ! Athralgia ! Bones fracture easily ! Bleeding gums ! Swollen gums " around central incisors; bluish; spongy # ! Pseudoparalysis " person does not move because of painful hemorrhage and tenderness of bones # ! Edematous swelling along leg shafts ! Anemia ! cant use Iron and Folate because Vitamin C helps with absorption. " Vitamin C, " absorption of iron, can lead to microcytic hypochromic anemia ! Sicca syndrome of Sjögren ! consisting of xerostomia, keratoconjunctivitis sicca, and enlarged salivary glands. ! Other clinical manifestations seen in infants as well as in older children and adolescents include swollen joints, purpura and ecchymoses, poor wound and fracture healing, petechiae, perifollicular hemorrhages, hyperkeratosis of hair follicles, arthralgia, and muscle weakness. ! Scorbutic Rosary ! at the costochondral junctions and depression of the sternum. The angulation of scorbutic beads is usually sharper than that of a rachitic rosary " in rickets #. ! DIAGNOSIS: " Bone atrophy " White lines of Fraenkel ! irregular but thickened white line at the metaphysis, represents the zone of well !calcified cartilage " Zone of Rarefraction ! linear break in the bone, proximal and parallel to the white line ! TREATMENT: # " 100!200mg orally " 3!4oz ' eshly squeezed orangejuic # " <2yo = 50mg " Excessive vit C can lead to formation of renal stones " Guava has the most vitc C !


 

Vitamin D #RICKETS

• • • • • • •

Secondary to vitamin D deficiency Occur before fusion of the epiphysis in GrowingBones Due to unmineralized matrix of growth plate Thickening of growth plate Widened ankles and wrists Generalized softening of bones and bone deformities CLINICAL MANIFESTATIONS: ! Craniotabes ! a softening of the cranial bones, can be detected by applying pressure at the occiput or over the parietal bones. The sensation is similar to the feel of pressing into a Ping !Pong ball and then releasing. “ballot!able cranium” ! Rachitic rosary ! Widening of the costochondral junctions ! Growth plate widening ! Big lumpy joints; responsible for the enlargement at the wrists and ankles ! Bowlegged ! Harrison groove ! occurs due to pulling of the softened ribs by the diaphragm during inspiration. Softening of the ribs also impairs air movement and predisposes patients to atelectasis. • ETIOLOGY OF RICKETS: ' Vitamin D disorders ' Calcium deficiency ' Phosphorus deficiency ' Distal renal tubular acidosis " RTA # • TREATMENT: depends on the cause refer to Nelson " chapter 48 #.


Vitamins • Micronutrients

Vitamin E Deficiency

• Red cell hemolysis ! Vitamin E is an antioxidant; maintains the integrity of the cell membrane • Posterior column and cerebellar dysfunction • Pigmentary retinopathy • 400mg is ENOUGH for adults • Vitamin A and E are fat soluble vitamins and have toxicities

Vitamin K

Important for clotting factors: 2, 7, 9 ,10 ! Too much vit K can lead to jaundice ! Intestinal flora produces vitamin K ! GI tract of newborn is sterile if CS, may not be sterile anymore if the infant is delivered vaginally. ! 3 forms of Vitamin K deficiency: 1. Early vitamin K deficiency bleeding % Hemorrhagic disease of the newbor , ! 1!4 days of life ! " Vit K due to poor placental transfer; no intestinal synthesis ! GI, mucosal, cutaneous, umbilical stump ! Intracranial bleed is less common bec this can be detected easily !

2. Late vitamin K deficiency bleeding ! 2!12 weeks, breastfed infants and born at home ! Occult malabsorption of vitamin K ! No vitamin K prophylaxis ! Intracranial bleed is most common ! + seizure ! APCD ! Acquired Prothrombin Complex Deficiency ! Bleeding normally in CNS ! Cutaneous and GI manifestations may be initial mx. ! Since we get vitamin K from intestinal bacteria, infants which have sterile GI tract, are susceptible to vit K deficiency 3. Vitamin K deficiency bleeding ! Occurs at birth or shortly after ! Maternal intake of warfarin, phenobarbital, phenytoin placental transfer interrupts vit k function ! Can also be seen in POST term infants due to "nutrient exchange


DIAGNOSIS ! Prolonged Prothrombin Time ! TREATMENT ! 1mg vit K IV / IM " routine procedure done to all newborns # ! If bleeding due to deficiency: can do 3x / day ! Adolescents: 2.5!10mg !

Micronutrients • IRON • IODINE • ZINC • FLOURIDE ! Children are more susceptible ! Absence of micronutrients can lead to organ damage " may be permanent # IRON " Fe # DEFICIENCY • Iron Deficiency Anemia ' Dose of iron depends on state of health ' Healthy: 1!2mg/kg/day elemental iron ' Patients who have iron deficiency: 5!8mg/kg/day " # give throughout the day; 3x/day ' Give on an empty stomach ! 30 mins ante cibum or 2 hours post cibum IODINE • For synthesis of thyroid hormone • Can get dwarfism with mental retardation if deficient ZINC • " morbidity & mortality for infectious disease • Helps with re!epitheliazation of GIT ! Given for any form of diarrhea " 10mg/day <6 months " 20mg/day - 6 months ! Supplement at 10mg/day FLUORIDE ! Best given topically " water or toothpaste #

BASIC PEDIATRICS DR. CALIGAGAN

Mirum: Vivamus est ipsum, vehicula nec, feugiat rhoncus, accumsan id, nisl. Lorem ipsum dolor sit amet, consectetuer

e s v c i i t r t n e a i v d e r e P P Principle of Health Supervision - pediatric visits 1. Health Promotions ! Acknowledge the complex forces that have impact on health, such as: familial, economic, educational, developmental and biologic entities.

4. Continuity & Coordination of Care ! For children with chronic condition a. Coordinate care b. Communicate with specialists c. Collaborate with family and community resources

2. Partnership ! Requires an appreciation of the context of each child & family by: a. Communication and understanding b. Educating families about health concerns c. Acknowledging their strengths d. Acquiring their trusts.

______________________________________________

Other topics of concern...

Topic of concern during health supervision visits:

Anticipatory guid. health main...

3. Communication a. Demonstrating respect and empathy b. Listening to concerns and conveying understanding c. Using non!judgemental, open! ended question ! to get more info ) d. O$ ering supportive comments e. Establishing relationship with children ! rapport 39 | prepared by cmgt

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

TEETHING SLEEP PROBLEMS NIGHT AWAKENING NIGHTMARES NIGHT TERRORS TOILET TRAINING NOCTURNAL ENURESIS TEMPER TANTRUMS DISCIPLINE PUNISHMENT

Other topics of concern in preventive pediatrics: A. Tobacco use B. Obesity C. Violence D. Media E. Parental Health Needs F. Reducing Cardiovascular Disease

Contents Principles of health supervision Topics of concern...

39 40 41 42

Screening tests

Cancer Child Abuse

43 43 44 45 45 46 47 47 48 48

Immunization

49

Newborn Screening Vision Hearing Tuberculin skin test Special Vaccination (travel) Injuries Obesity Dental Caries

Schedule of health supervision visits __________________________________________________________ NOTE: This can be interrupted anytime.

PERIODIC HEALTH SUPERVISION VISITS SHOULD INCLUDE:

a. Clinical history and physical examination b. Screening c. Immunization d. Surveillance of dev. milestone e. Observations of parent-child interaction f. Anticipatory guidance counseling g. Opportunity to address concerns and questions

Infancy 0-1year Neonatal Prenatal 1st week 1 month 2 months 4 months 6 months 9 months 12 months

TOPICS OF CONCERN DURING HEALTH SUPERVISION VISITS 1. TEETHING: ! Most infants have their 1st tooth erupt at age 6!8mos ! May have mild symptoms of gingival swelling and sensitivity. ! Lack of association " no direct correlation # to: # Fever # Drooling # Diarrhea # Rashes # Mood disturbances # Sleep disturbances 2. SLEEP PROBLEMS Educate parents about: ! Separation anxiety, which develops in the latter half of the 1st yr. of life. ! Normal sleep requirements to help them understand a child’s need for naps, sleep schedules and bedtimes. To help child settle with 1. Establish a regular bedtime routine starting with a quiet interaction like reading a bedtime story. 2. Allow infants to settle on their own so that they accomplish a successful independent transition to sleep. 3. If child protests, parents should use the same consistent approach repeatedly. 3. NIGHT AWAKENING ! Parents should delay response so arousal states do not progress to complete awakening. ! Use the same approach of promoting nighttime settlings. 4. NIGHTMARES ! Common, vivid, scary or exciting events easily recalled by the child upon awakening 5. NIGHT TERRORS ! Less common events lasting 10!15 minutes, during which time the child is not easily aroused and may appear frightened and agitated. ! On awakening the next morning, have amnesia ! Emphasize a calm and soothing approach to facilitate the child’s return to sleep. 40 | prepared by cmgt

Early childhood 1-4 years

Middle childhood 5-10 years

15 months 18 months 2 years 3 years 4 years

5 years 6 years 8 years 10 years

Adolescent 11-21 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years

5. TOILET TRAINING ! Key factor: Readiness of a child ! Average age of successful toilet training: " 1960’s # 27!28 mos. " 1900’s # 35!39 mos. ! Early training " <2 yrs old # should be discouraged due to its association with chronic stool retention and encopresis. ! Positive reinforcement and regular toilet times. ! Give calm and understanding support. 6. NOCTURNAL ENURESIS ! Positive reinforcement and regular toilet times. ! Occurrence of involuntary voiding at night at 5years old. 7. TEPMER TANTRUMS ! Child’s expression of anger in outburst of rage ! Normal part of a child’s development. ! Types: a. Frustration or fatigue related • Give support, secondary to sleep or food • Positive remarks

b. Attention seeking or demanding

• Ignore the and allow them to regain composure over time

c. Refusal " related to bedtimes and school #

• Parents should be clear in their request for the child to comply and must allow opportunity for compliance • Should be approach with firmness

d. Disruptive

• Physical removal followed by a time !out " 1 min/year of age #

TIME OUT ! Removal of positive reinforcement for

unacceptable behavior. ! This technique requires consistency and

patience

e. Potentially harmful or rage!like ! Best intervention is holding the child to calm and allow him or her to relax in the parent’s arm.

...cont. Topics of concerns

NOTE:

! Temper tantrums are normal part of childhood and ! !

parenting It is important to asses the family Determine if there are contributing factors: Parental depression o Family violence that may require other o referrals and interventions

8. DISCIPLINE ! Parents have a tendency to apply discipline strategies similar to those used by their parents. ! Inquire about methods of discipline and o $ er practical advice and alternatives. ! A positive, supportive and loving parent !child relationship ! Instruct to maintain a positive atmosphere within their home ! Advise parents to provide clear expectations about desired behavior. Cornerstone for e$ ective discipline includes: a. Consistency of parental behavior b. Open communication within families c. Mutual respect - Referral for counseling is the most important priority if there is marital discord, drug or alcohol abuse. Verbal reprimand may become abusive when reprimands do not address undesired behavior but rather, assault the characteristic of a child. 9. PUNISHMENT ! Involves issuing a negative stimulus or verbal reprimand, or inflicting physical pain, to reduce or eliminate an undesired behavior. ! Physical punishment may be harsh and abusive ! Pediatrician must remain empathic, flexible, committed to their relationship with the families.

UNMET NEEDS AND FUTURE CHALLENGE IN PREVENTIVE PEDIATRICS The Future: 1. New immunizations 2. Improved screening tests to provide early diagnosis. 3. Unique genetic info to individualize preventive and therapeutic strategies 4. Enhanced treatments that minimize the impact of chronic condition.

OTHER TOPICS OF CONCERN IN PREVENTIVE PEDIATRICS 41 | prepared by cmgt

TOBACCO USE: ! Eighty " 80&# of people who smoke had their 1st cigarette before 18 yrs of age: ! Cigarette smoking . is the most preventable cause of mortality and morbidity in US today. ! Parental disapproval of smoking may prevent adolescents from established smokers ! Brief education messages that explain relationship of smoking to: Lung cancer o Ischemic heart disease o Low birth weight can promote smoking o cessation OBESITY ! Childhood obesity is an epidemic in the US ! Type 2 diabetes mellitus incidence is increased. VIOLENCE ! Permeates the lives of children ! Homicide, suicide, child abuse, domestic violence, access to fire arms, substance abuse, school shootings, gang participations, media violence, date rape, bullying and terrorist acts are examples of the daily infiltration of violence into the lives of children. MEDIA INFLUENCES ON BEHAVIOR ! Growing evidence that demonstrates the impact of media, particularly Television, on the health of the children. ! There are untoward e$ ects in terms of violence and aggressive behaviors, substance abuse, sexual activity, body image, school performance, and obesity. ! This influence is related to content and total viewing time. ! 1 to 2 hours per day " normal viewing time # PARENTAL HEALTH NEEDS Studies have shown that parental health status, for example, maternal depression Has significant influences on adequacy of o preventive health services for children. LITERACY PROMOTION positive e$ ect of early educational interventions on subsequent cognitive development of children demands that pediatrics play a role in promoting this o aspect of family life and early childhood development REDUCING CARDIOVASCULAR DISEASE

ANTICIPATORY GUIDANCE ON HEALTH MAINTENANCE PRACTICES

Preconception -

Talk to parents about the different causes of high risk infants and their preventive measures.

-

Proper spacing of pregnancies and limitations of the number of children should be encouraged.

-

Government measures which contribute to the well-being of the prospective child: 1. Setting of minimum age for marriage 2. Banning marriages between 1st and 2nd degree relatives 3. Premarital counseling

-

Non-immune woman should be immunized against tetanus and rubella long before they become pregnant.

-

Non-immune pregnant woman in their 1st trimester must be given immune globulin upon exposure to rubella.

-

Genetic counseling among couples wit h heredofamilial disease is important.

-

Beg in pro gra m of hea lt h promotion which includes preparation for breast feeding.

-

Tetratogenic drugs, exposure to Xray, smoking and alcoholism must be avoided during pregnancy.

Preschool & School Age -

2 - 5 years old Increase rate of growth, skills in social activities, motor formation, acceptance of responsibility, habit formation.

-

Physical and mental afflictions not detectable at birth may manifest in this age group

-

Vitamin and Iron supplementation if needed

-

Update immunization

-

Stress hygiene to prevent intestinal parasitism

Prevent dental caries Better locomation (they are more prone to accidents)


Neonatal -

0 - 28 days

-

Newborns delivered by CS (do not expel out secretions) need Gastric lavage (not used often)

-

ROUTINE NEWBORN CARE: 1. Wrap in a clean blanket to prevent hypothermia 2. Maintain normal body temp (36.5-37.5 $). Temperature may be taken per rectum or axilla every 4hrs stable, then every 8hrs thereafter. 3. Vitamin K, 1mg deep IM to prevent Hemorrhagic Disease of the Newborn. (remember that gut flora produce Vitamin K. Since the GIT of the newborn is sterile, there is a need to give VitaminK. VitaminK is important clotting factor, without this the baby could suffer from severe intracranial bleeding). 4. Eye Prophylaxis - to prevent Ophthalmia Neonatorum. a. 1% silver nitrate (can cause chemical conjunctivitis) b. 0.5% erythromycin c. 1% tetracycline d. 2.5% povidone-iodine 5. Antiseptic and cord care - to prevent infection, cleanse with warm matter or with mild soap. Wipe the cord from base to top with 70% ethyl alcohol. 70 percent alcohol, betadine and bacitracin can be used.

Clear the mouth, pharynx and nose of fluid, mucus, blood and amniotic debris by gravity or by gentle suctioning (so the baby can breath well)

Infancy -

0 - 2 years old

-

What to do: • Examine and access the anthropometric data • Supervise nutrition and administer immunization • Anticipatory guidance in injury prevention • Post exposure to drug prophylaxis • Relationship between parent and infant should be assessed at all times. • Teach about the care of the infant, burping, care of the mouth,teeth,and external genitalia, etc.

Questions to ask: 1. Care & feeding of the infant 2. Developmental changes 3. Occurrence of symptoms during the interval between visits.

Puberty & Adolescence -

-

Physical & health problems decreased during this stage Morbidity and mortality are at their lowest The problems are: 1. Physical - growth & dev 2. Psychologic - adjustment prob 3. Educational 4. Nutritional Those who had a happy childhood find less difficulty in adjustment. Physical health problems of adolescence are not serious in nature and less frequent.

- What to do? •Periodic health assessments preferably unaccompanied by their parents 1. Gives opportunity to talk freely 2. Feeling that he is being treated as a mature person 3. Opportunity to discuss problem 4. Opportunity to talk on sensitive topics •Preventive measure: 1. Educate both parents & adol. 2. Be prepared to recognize early signs of serious probs before the crisis occurs 3. Convince the parents & adol to talk about concerns

SCREENING TEST FOR HEALTH PREVENTION NEWBORN SCREENING " neonatal screening # "

Simple procedure to find out if the newborn has a congenital metabolic disorder. " Most babies with met. disorder look normal at birth. " Done on the 24th hr of life or ideally on the 48 hr " Screen again after 2 weeks for more accurate results. " Done by heel prick method with few drops of blood blotted on a special absorbent filter card, dried for 4 hours then sent for the NIH at the UP"PGH " Negative scree, . result is normal " Pos it iv e scre e , . immediately recall patient for confirmatory testing PHILIPPINES NEWBORN SCREENING PROGRAM

1. Congenital Hypothyroidism ! Most common inborn metabolic disorder ! Due to lack or absence of thyroid hormone ! If no hormone replacement within 4weeks, results to stunted physical growth and mental retardation ! TSH assay recommended as early as day 1.

2. Congenital Adrenal Hyperplasia $CAH% ! Enzyme defect of cortisol synthesis ! Causes severe salt loss, dehydration, high level of male sex hormone ! Babies may die within 9!13 days if not treated

3. Galactosemia $GAL% ! Failure of galactose utilization due to deficiency of

!

Galactose 1!phosphate uridyl transferase Accumulation of excessive galactose results to cirrhosis, cataract, mental retardation and death.

4. Phenylketonuria $PKU% ! Cannot use Phenylalanine "Phe# ! Causes brain damage 5. Glucose 6 phosphate dehydrogenase deficiency $G6PD% ! Prone to hemolytic anemia due to oxidative substances found in drugs, foods and chemicals.

VISUAL ACUITY TEST In infants: • Assessment of their ability to fixate and follow a target usually by a bright colored toy 2 # to 3 years old • Schematic picture or illiterate eye contact E! test ! Most widely used visual acuity test for pre!school.

PRE-SCHOOL VISION SCREEN ING ! Is a means of decreasing preventable visual loss ! Done by a pediatrician during well child visits ! Examination by an ophthalmologist is needed when: • There is ocular abnormality or visual defect noted • There is risk of ophthalmologic problems such as genetically inherited ocular conditions. I. Visual field!assessment ! Formal visual field assessment " Perimetry and Scotometry # can be accomplished in school !aged children ! Confrontation technique and finger counting are most used ! Can often detect significant field changes II. Color Vision Testing ! Fundus examination: best done with pupils dilated ! Refraction determines degree of nearsightedness, Farsightedness or astigmatism. III. Cornea light reflex test ! Most rapid diagnostic test on strabismus " common among children; physiologic squint only until 6mos # ! Projects light source onto the cornea of both eyes ! Straight eyes light reflection appears symmetrical ! Strabismus: reflected light is asymmetric

WAYS IN WHICH VISION LOSS MAY LIMIT DEVELOPMENT:

1. They do not receive full information 2. They are not motivated to move out into space 3. Loss of control DEVELOPMENT AREAS THAT ARE AFFECTED:

1. PHYSICAL: strength, coordination, range of motor skills.

Vision 1!3 months old

tears are present with crying

3!6 months old

proper coordination of the eye movement

3 years old

visual acuity of 20/40

4 years old


5!6 years old


2. COGNITIVE: range and depth 3. SOCIAL: non! verbal communication OCCULAR DISORDERS CAUSING VISUAL LOSS IN PEDIATRIC AGE GROUP:

1. Ocular anatomy 2. Disorders of cornea !ulcers . tears in descemets 3. Posterior segment disorders: a. Retinitis pigmentosa b. Retinoblastoma c. Optic nerve disorders 4. Cataracts ! most common cause is congenital rubella.


...cont. Vision

STEPS THAT YOU CAN TAKE TO HELP CHILDREN DEVELOP: $ Teach $ $

skills Change environment Give assistance to prevent secondary handicaps

ASPECTS OF VISION LOSS:

RISK FACTORS ! Indicate a need for testing during first few mos of life

1. 2. 3. 4. 5. 6. 7. 8.

Family history of deafness Prematurity Severe asphyxia Use of ototoxic drugs in the newborn period Hyperbilirubinemia Congenital anomalies of the head and neck Bacterial meningitis Congenital infection due to TORCH

RISK FACTORS FOR HEARING LOSS

1. 2. 3. 4. 5. 6. 7. 8.

WHAT IS A CHILD’S FUNCTIONAL VISION:

1. Usable vision 2. Peripheral vision: navigation 3. Central vision: for reading/ spotting

Asphyxia " low APGAR Score < 3 # Bacterial meningitis Congenital perinatal infections TORCHS Defect of the head and neck Elevated bilirubin Family History Birth weight of <1.5 kg

AUDITORY ASSESSMENT A. Behavioral Assessment

Hearing

1. BEHAVIORAL OBSERVATION AUDIOMETRY (OAE) ! < 6 months old

Normal Auditory Milestones

2. VISUAL REINFORCEMENT ORIENTATION AUDIOMETRY (VROA) ! 6 months!3 years old

0!4 months

Awake to loud sounds

4!7 months

Turns toward sounds

7!12months

Imitate sounds

18 months

3 word vocabulary

2 years

20!30word vocabulary & 2word sentences

3.PLAY AUDIOMETRY ! > 3 years old B. Objective Assessment

HEARING IM PAIRMENT INCIDENCE WHO: # 1!3 / 1000 ! live births # 1:1000 ! with profound deafness # 1:1000 ! with acquired deafness in early childhood In 1991: # 600,000 Filipinos with hearing impairment

HEARING LOSS SCREENING TEST AUDIOMETRY or BRAINSTEM-EVOKED POTENTIAL

! ! ! !

TESTING

Mandatory for any child suspected of hearing loss Normal hearing infants # turn their head toward a physical stimuli Normally intelligent hearing !impaired toddlers are universally alert and respond appropriately to stimuli , Parental concern is often a reliable indicator of hearing impairment and warrants a formal hearing assessment.


1. OTOACOUSTIC EMISSION ! Assesses the cochlear status 2. OTOSCOPY ! Detects impacted cerumen, aural atresia and auditory canal stenosis

RESPONSIBILITIES OF A PEDIATRICIAN 1. 2. 3. 4.

Investigate on the risk factor Monitor language development Inform parents of the availability of screening tests Refer to appropriate specialists without delay.

EFFECTS OF LATE DETECTION AND INTERVENTION FOR HEARING LOSS 1. 2. 3. 4. 5.

Delay in language acquisition Poor communication Skills Social and emotional immaturity Poor educational development Poor quality of life

Tuberculin Skin Test TUBERCULIN TEST or PURIFIED PROTEIN DERI VATIVE (PPD TYPE 4) ! Method to determine persons who are infected with Mycobacterium tubercolosis & who do not have TB disease.

! Safe and cost!e$ ective test used worldwide as a clinical and epidemiology toll for TB diagnosis and tuberculin surveys. ! Based on a delayed hypersensitivity reaction $ $

PPD $ + ! ( infected with TB Type 4 ( delayed type of hypersensitivity

Features of the Delayed Hypersensitivity Reaction

1. Its delayed course ! Reaction starts 5!6 hours after injection ! Maximal induration is noted within 48 !72 hours post injection and subsides over a period of days.

FALSE NEGATIVE Mantoux test may be due to: 1. Factors related to the person being tested. a. Energy b. Very young age " <6 months # c. Recent TB infection d. Overwhelming TB disease e. Live! virus vaccination " OPV, Varicella, MMR # $ Tuberculin test should be administered either on the same day as the vaccines of 4!6 weeks after f. Immunosupression 2. Factors related to the tuberculine used: a. Improper storage b. Improper dilution 3. Factors related to the method of administration a. Too little antigen b. Too deep injection 4. Factors of error in reading & recording of results

2. Its indurated character ! The area of induration " palpable raised hardened area # around size is the reaction to tuberculin

! Diameter of the indurated area o

Measures in millimeter transversely to the long axis of the forearm by: Palpation Ballpoint technique! draw a straight like from 5 !10 mm away from both the opposite sides of the margin of the skin induration and drawn towards the center until a resistance is felt. ! !

3. Is occasional vesiculation and neurosis MANTOUX TEST

! Standard and recommended method of giving the tuberculin for screening ! 0.1 ml of either 2 TU of PDD RT23 or the 5TU of PDD!S intradermally into the volar aspect of the right forearm. ! After 48!72 hours ask the patient to come back for reading ! Positive tuberculin test: 5 and 10 = condition is positive ! Positive reactions: • - 5mm with the following factors: ! Exposure to an adult with TB ! " + #Xray with TB!/" + #Xray and " + #exposure0 ! s/s of primary complex • - 10 mm without factors " routine testing only #

FALSE POSITIVE Mantoux test may be due to:

1. Non ! tuberculous Mycobacteria $NTB% 2. BCG Vaccination ! Most patients who receive BCG lose their cutaneous hypersensitivity reaction within 5 years. 45 | prepared by cmgt

Traveling HEALTH ADVISE FOR CHILDREN T RAVELING

! Seek consultation 4!6 weeks before departure ! For those with medical problem: 1. Medical summary 2. Su)cient supply of medication 3. Directory of physicians 4. Travel health kit ! Safety: 1. Use safety belts 2. Avoid stray dogs, venomous animals & scorpions 3. Avoid swimming in contaminated water SPECIAL VACCINATIONS FOR TRAVEL: 1. CHOLERA ! Should be at least 3 weeks apart from yellow fever vaccination ! Oral cholera vaccine for 2 years old and above 2. JAPANESE ENCEPHALITIS ! For children 1 year and older ! Administered 3 doses subcutaneously ! Should be completed 2 weeks before travel 3. MENINGOCOCCAL ! For children 2 years and older ! 0.5 ml SC/IM 4. TYPHOID FEVER ! Given IM for 2 years and above 5. YELLOW FEVER ! Mosquito borne viral illness ! Vaccine to children >5 months old traveling to an endemic area ! Live attenuated vaccine 0.5 ml SC

6. RABIES ! Facial bites are more common in children ! Medical emergency in rabies endemic areas

POST EXPOSURE DRUG PROPHYLAXIS

Injuries INJURIES

! Most common cause of death during childhood and adolescence beyond the first few months of life A. Fall

!

Leading cause of both emergency visit and hospitalization

B. Bicycle related trauma ! Most common type of sports and recreation injury

SCOPE OF INJURIES 1. Motor vehicle injury ! Leading cause of death due to accidents among adolescent

2. Drowning ! Peak in the preschool and late teenage years. ! Leading cause of death in children ! Near drowning ! resuscitated after drowning " alive # ! Successful drowning ! dead 3. Fire and Burn ! 6& of all unintentional trauma deaths ocation 4. Su& ! Half of unintentional deaths in less than 1 year old 5. Homicide $inflicted and intentional % ! Two patterns of homicide: o

INFANTILE HOMICIDE <5 years old Represent child abuse Perpetrator is usually a caretaker ! ! !

ADOLESCENT HOMICIDE Involves peers and acquaintances Due to firearms in >80 & of cases Suicide ! increased markedly after 10 years old o

! !

!

PRINCIPLE OF INJURY CONTROL

1. Examine the physical and social environment 2. Injury control includes:

a. Education of parents to change their behavior i. Child car seat restraints ii. Bicycle helmets iii. Smoke detectors b. Changes in product design i. Child resistant caps on medicine c. Modification of social and physical environment i. Dec. speed limits in the neighborhood ii. Eliminate guns from households


PEDESTRIAN INJURIES

! Most common cause of traumatic coma Prevention of pedestrian injuries 1. Education of the child in pedestrian safety 2. Major streets should not be crossed alone until the child is 10 years old. 3. Measures to slow the speed of tra )c and route away from school and residential areas. 4. Proper placement of bus stops and sidewalks.

FIRE AND BURN ! 6& of all unintentional trauma deaths Fire and Burn Related Injuries Prevention 1. Not drinking hot drinks while holding an infant 2. Keeping children away from cooking areas 3. Use on non!flammable fabrics 4. Check tap water temperature 5. Adult supervision of use of all fireworks

NUTRITIONAL GUIDELINES FOR FILIPINOS

1. Eat variety of food everyday 2. Breastfeed infants exclusively from birth to 6 months and then give appropriate foods while continuing breastfeeding. 3. Maintain children’s normal growth through proper diet and monitor their growth regularly. 4. Consume fish, lea meat, poultry and root crops. 5. Eat more vegetable, fruits and root crops. 6. Eat foods cooked in edible cooking oil daily. 7. Consume milk, milk products and other calcium rich food such as small fish and green leafy vegetable. 8. Used iodized salt but avoid excessive intake of salty foods 9. Eat clean and safe foods to prevent food!borne diseases. 10. For a healthy lifestyle and good nutrition, exercise regularly, do not smoke and avoid drinking alcoholic beverages.

Obesity Obese ! BMI is >95th percentile or 20& higher than the ideal body weight Overweight ! BMI is between 85 th . 95th percentile Underweight ! BMI is < the 5th percentile

BMI $kg/m 2% <16.0 16.0!17.0 17.0!18.5 19.0!24.9 25.0!29.9 30.0!34.9 35.0!39.9 >40.0

WHR = _waist circumference $cm % _ hip circumference $cm % Normal WHR: <1 for men <0.85 for women Central Obesity: >1 for men >0.85 for women 47 | prepared by cmgt

DENTAL CARI ES ! Remained increased in low income group. ! Depend on interrelationship between the tooth surface, dietary carbohydrates and specific bacteria

BMI = _weight $kg% _ height $m2% CLASSIFICATION Severe malnutrition Moderate malnutrition Mild malnutrition Normal weight Overweight Class 1 obesity Class 2 obesity Class 3 obesity

Dental Hygeine

Normal waist circumference: <102 cm for men <88 cm for women

RISK FACTORS FOR THE DEV OF DENTAL CARIES:

1. Increased sugar consumption 2. Prolonged and frequent drinking and sipping 3. Low socio!economic group

Preventive Meas ures: 1. Fluoride ! Added to drinking water is ! best preventive measure ! Topical Fluoride ! Fluoride 2. Oral hygiene ! Daily brushing with fluoridated toothpaste 3. Diet ! Decrease sugar ingestion 4. Dental sealants ! Sealants are resins applied on the teeth ! Most e$ ective when placed soon after teeth erupt " within 1!2 years # in deep grooves and fissures.

Cancer ! 2nd leading cause of death by disease !

Factors that may account for about 75% of all cancers:

1. 2. 3. 4.

Tobacco ) lung cancer " esophageal cancer # Sexual Behavior ) invasive cervical cancer Diet ) colorectal cancer Alcohol ) esophageal cancer " liver cancer #

! ! ! !

Primary Cancer P revention in Pediatric Practice:

1. Decrease lung cancer ! Prevention of tobacco in all forms 2. Decrease cervical cancer ! Altering sexual habits in teenagers 3. Decrease breast and colorectal cancer ! Dietary modification 4. Decrease oral and esophageal caner ! Decrease alcohol usage LUNG CANCER

The Socio!Psychological Lung Cancer Prevention: 1. Providing information to the youth that smoking is deleterious 2. The children role play to see how to resist the social influence to smoke from family and peers 3. The decision making and commitment in public not to smoke

! !

CRYPTORCHIDISM Undescended testes Most common disorder of sexual di$ erentiation in boys Majority spontaneously descend during the 1st 3months of life Consequences: 1. Infertility 2. Malignancy 3. Associated hernia 4. Torsion 5. Psychological E$ ect of empty scrotum Orchiopexy should be done at 9!15months

! !

especially if between 15"17 years of age. Prevention: 1. Counseling adolescents regarding sexual activity 2. Initial sexual history & discussion of contraceptive 3. Sexually active = screen annually 4. All suspicious " + # signs of cervical pathology should be biopsied.

BREAST CANCER Prevention: 1. Self breast examination monthly 2. Periodic professional breast examination 3. Screening mammography for 35 years of age and above

TESTICULAR CANCER: Risk Factors: 1. Undescended testes 2. Atrophic testes " 1& of all inguinal testes and 5 & of abdominal testes will become malignant Prevention: 1. Monthly testicular self !examination 48 | prepared by cmgt

Report suspected child abuse within 48 hours Non!reporting: fine of Php 2,000.00

TYPES OF CHILD ABUSE:

1. PHYSICAL ABUSE

a. b. c. d. e.

CERVICAL CANCER ! Increased incidence in adolescents ! Most important risk factor is the age at first coitus

Child Abuse

Bruising Burns Fracture Head injuries from routine falls Shaken Infant Syndrome % 50& of death of children caused by non ! accidental trauma

2. SEXUAL ABUSE ! Decide which physical injuries are accidental and

! ! ! !

which are abusive Accidental bruising is more common in 2!5 years old who are still developing their coordination and motor skills In a healthy child, in the absence of a traumatic history to produce a fracture, the first diagnosis should be abuse Suspect abuse in child with serious head injury or evidences of repeated inflicted injuries Retinal hemorrhages associated with subdural hematomas in children <2 years old should be considered child abuse.

Prevention: 1. Convey to all parents never shake their small children, to avoid Shaken Baby Syndrome. 2. Diagnosis and treatment must be swift to avoid sepsis and hypovolemic shock. 3. Always check the abdomen of an abused child for tenderness and do trauma !screening laboratory studies. 4. There should be a meticulous search for other injuries. 5. Careful follow !up to document and treat sequelae of trauma.

6. 7. 8. 9.

Psychological assessment of the caretakers Child protection needs to be available immediately Home visitation program and unannounced visits. To decreased the risk of SIDS " Sudden Infant Death Syndrom$ #: a. Put the baby on his or her back to sleep b. Let the baby sleeps on a firm mattress or surface c. Have a smoke free & comfortably warm room d. Regular doctor/clinic visits. e. Early and regular prenatal care.

•

'i ( and Rou ( of Immuniza" o# 1. PER OREM " PO # ! Breastfeeding doesnot interfere with oral vaccination ! If there is vomiting within 10 mins of vaccination, repeat the dose " for opv # ! The only 2 vaccines administered PO: ! OPV and Rotavirus

2. INTRAMUSCULAR " IM # ! Based on the volume & size of the muscle ! Anterolateral aspect of the thigh !for < 1 yearold; ! !

!mmuniza" o# Provision of an individual with antibodies possessing power to destroy or inactivate the disease producing agents or neutralize it’s toxin.

! !

to avoid hitting the Sciatic Nerve. Deltoid area ! for older children Buttocks ! rarely used. There are more fats than muscle in this area. Some vaccines will loose their potency if given through this area because it will just go to subcutaneous fats " hepa B vaccine # Eg DTP, Hepatitis B vaccines Everything else aside from those given through PO, SQ and LD

$ Ultimate goal : Eradication of the disease

" ex. Small pox is eliminated because of immun. # $ Immediate goal : Prevention of dse in an individual

" ex. DPT # $ ACTIVE IMMUNIZATION

! Administration of the microorganism or its modified product to evoke an immunologic response ! Immunologic response ! give the antigen to initiate the body to produce antibodies ! Takes a wh il e to take effect bu t wi th pr ol on ge d protection

$ PASSIVE IMMUNIZATION ! Administration of a preformed antibody to a recipient

! Immediate response but protection lasts only for a short period of time ! Eg. Rabies and tetanus vaccine

$ lassi % ca" on of Vaccine& • LIVE ATTENUATED ! Actual infection ensues after administration with little or no adverse host reactions Attenuated: these are live, weakened microorganisms ! so part of the reaction of vaccines are side e $ ects which include signs and symptoms of mild form of rash, little fever, not enough to cause much harm to the patient ! Eg. BCG, measles, MMR, Rotavirus, varicella " chicken pox # , Influenzae " i ntranasal type not available in the Philippines • KILLED ! Not capable of replicating in the host and must contain a su)cient antigenic mass to stimulate a desired " usually with carrier # ! Eg. DTP, HIB, meningococcal, Pneumococcal, IPV, Rabies 49 | prepared by cmgt

3. SUBCUTANEOUS " SQ # ! 45º angle into anterolateral aspect of thigh or upper outer triceps ! Eg. Measles, MMR, Varicella

4. INTRADERMAL " ID # ! Volar aspect of the forearm ! Eg. BCG ! deltoids on the right side 5. INTRANASAL ! Upright position, 0.25 ml is sprayed into one nostril, the 2nd half is administered to the other nostril ! Sneezing after administration : may not repeat ! Eg. Live attenuated influenza vaccine " 5!49 yo # ! not available in the Philippines

'cheduling Immuniza" on& ANTIGEN COMBINATION

RECOMMENDED MINIMUM INTERVAL BETWEEN DOSES

      

               

     

               

        

         

$ 12mos 12mos accdg to handbook !

NOTES: • D - toxoid P - killed T - toxoid • P component - P (w) - whole cell - given in health ctrs; w/ side effects P(A) - acellular - more expensive, less irritating less side effects DPT and OPV are given at the same time in health ctrs • • 4 in 1 - Polio, DPT 5 in 1 - Polio, DPT, Hib, PV 6 in 1 - Polio, DPT, Hib, Hepa B


Hepa B •016 • 0 1 2 + 1 booster 1 year after $ EPI vaccines

- BCG, DTwP (DPT), OPV, Measles, Hepatitis B, MMR, Hib

$ Other

recommended vaccines - MMRV, Hepa A, DTaP, Tdap (DPT), IPV, Pneumococcal, Rotavirus, Influenza, HPV vaccine.

$ Vaccines

for special groups - Meningococcal, for Typhoid, Rabies

Hypotonic Hypotonic hyporesponsive episodes " HHE HHE # “collapse” or “shocklike “shockl ike state” - Fever of 40.5 ºC within 24hours of administration - Incessant crying -

aci * BCG ) aci * e Calme+ e Guerin , BCG ! ! ! !

Prevents extra !pulmonary manifestations pulmonary manifestations of tuberculosis Live vaccine ) Given anytime after birth ! accdg to ppt Should be given at the earliest possible time preferably # within the first 2 months of life $ accdg to prev. ped health car # handbook, 2010 !

! 2nd month of life ! do PPD first! ! For healthy children >2months who are not given the

!

! ! ! !

BCG @birth, PPD prior to BCG vaccination is NOT prev. ped health care handbook, 2010 ! necessary. $ accdg to prev. PPD prior to BCG vaccination is recommended if: • Susp Suspec ecte ted d conge congeni nita tall TB • History History of close contact contact to known known or suspected suspected infectious cases of TB • Clinical findings and/or chest Xray suggestive Xray suggestive of TB. In presence of any of these conditions, an induration of -5mm is considered positive. ROUTE: Intradermal " ID ID # ) ) DOSE: 0.05ml ! infants < 1 mo ! <12mos accdg to handbook <12mos ) ) 0.1 ml ! infants > 1 mo ! >12mos accdg to handbook >12mos NATURAL COURSE: Wheat formation ! disappears 30mins post!injection Induration ! occurs 2!3weeks post!injection Pustule formation ! after 2!3weeks of induration Ulceration ! after 5!6weeks post!injection Scar formation $ sign of healing ! 8!12weeks post!injection

ADVERSE REACTION: REACTION: ! ADVERSE - Koch’s phenomenon ! accelerated BCG formation - Indolent ulcers ! ulceration of more than 3weeks - Uncommonly " 1!2&# result in local adverse reactions - Subcutaneous abscess llymphadenopathy ymphadenopathy - Osteomyelitis and muscle necrosis

" injected injected too deeply,

instead of ID, ID, IM was done #

. iph iph/eria, Pertussis, & Tetanus , DPT DPT ! Inactivated Vaccine ! AGE: as early early as 6weeks old ! PRIMARY SERIES INTERVAL: 4weeks apart for 3 doses ! BOOSTER DOSES: • 1st ! 1 year after last dose • 2nd ! at 4!6 years old ! ROUTE: Intramuscular " IM IM # ! DOSE: 0.5 ml ! ADVERSE ADVERSE REACTION: REACTION:

Local and febrile reactions - Bacterial or sterile abscess at the site of infection are infrequent - Allergic reactions - Seizures -


inactivated DTP with whole !cell pertussis ! DTwP " inactivated component # is included in EPI in EPI ! DTaP " with acellular pertussis component # # and Tdap " for for adolecents and adults # are included in other

recommended vaccine prev. ped health care handbook, handbook, 2010 ! : ! Tdap $ accdg to prev. &

' ular Tetanus and diphtheria toxicoids and ace ular pertussis ! Tdap ) % given intramuscularly ! ). Children and Tdap ) IM $ adolescents 10%18years of age should receive a singl $ do se of Tdap Td ap in st ea d of th e Td fo r th e bo oste os te r immunization against tetanus, diphtheria and pertussis if they have not completed the recommended childhood DTwP/DT DTwP/DTaP aP immunization series and if they hav$ & er not received either Td or Tdap. Therea & er Td booster given every 10 years is recommended. An interval of # omthe atleast 5 years # omthe last td dose is recommended if the Tdap is used as a booster to reduce risk of local and systemic reactions

0 olio olio Vaccin1 Oral Polio Vaccine Vaccine # is included in EPI in EPI ! OVP " Oral Inactivated Vaccine # are included in other ! IVP " Inactivated recommended vaccine AGE: as early as 6weeks old ! AGE:

! PRIMARY SERIES INTERVAL: 4wks apart for 3 doses ! BOOSTER DOSES: • 1st ! 1 year after last dose • 2nd ! at 4!6 years old PO # ! ROUTE: . OPV ! Per Orem " PO . IVP ! Intramuscular " IM IM # ! DOSE: 0.5 cc or 2 drops ! ADVERSE ADVERSE REACTI REACTION: ON: - OPV ! vaccine associated paralytic polio " VAPP VAPP # ! Can cause epidemic. - IPV ! Hypersensitivity reaction

2 MR MR - Measles, Mumps, Rube *3 !

$ accdg to prev. prev. ped health care handbook, handbook, 2010 ! : & &

Classified under EPI. EPI. ) . The minimum age is Given Subcutaneously ! SQ SQ 12months. Administer the second dose at age 4 through 6 $ years. However, However, the 2 nd dose maybe administered befor $ age 4 provided an interval of 28 DAYS has elapsed since the first dose.

MRV - Measles, Mumps, Rube * a, a, Chicken Po 4 2 MRV & &

Classified under recommended vaccines ). Combination MMRV can b$ Given Subcutaneously ! SQ SQ given as an alternative to separately administered MMR and Varice ' a vaccine for healthy children 12months to 12 yearas of age. age.

aemophilus In 6 uenzae uenzae Type B , Hib Hib vaccine - 5 aemophilus ! Inactivated Vaccine ! AGE: AGE: 2 months ! Children:  <6months: 3 doses at 2 months apart  6!12 months: 2 doses, 2 months apart

> 1 year old: 1 dose ! ROUTE: IM or SQ ! DOSE: 0.5 cc 

2 easles easles Vaccin1 ! ! ! ! ! !

Live Attenuated vaccine AGE: 6!9 months 2nd dose ! 6 months after the first " as as MMR # rd 3 dose ! 4!6 years old DOSE: 0.5 ml ROUTE: Subcutaneous " SQ SQ #

! ADVERSE ADVERSE REACTION: REACTION: - Fever 5 !7days from time of injection - Local swelling or pain

7 arice arice* a Vaccine , chicken chicken pox ! Administer Administer 2 dose series to all susceptible adolescents

aged greater than or equal to 13 years ! AGE: AGE: 12!18 months ! 1 dose for universal immunization AGE: 19 months!13 years old: susceptible children ! AGE: prev. ped health care handbook, handbook, 2010 ! : ! $ accdg to prev. &

from site of injection

- Mild rashes

! PASSIVE immunization # # # #

Insusceptible Insusceptible and immunocompromised patients Give immunoglobulin within 6 days after exposure Dose: .25cc/kc IM IVIG at a dose of 100 !400 mg/kg

!

&

prev. ped health care handbook, 2010 ! : ! $ accdg to prev. &

Given SC. The first dose of the vaccine is administered at 12 % 15mons. A 2 nd dose of varicella vaccine is re r e c o m m e nd e d a t a ge 4% 6years old but may b $ administered administere d at an earlier age provided the interval between the 1 s and 2 nd dose is AT LEAST 3 MONTHS. A 2 nd dose of the vaccine is recommended for children, adolescents, adults who previously received only on$ ' individuals dose of the vaccine. A individuals aged 13 years old and above, without previous evidence of immunity, immunity, should ' receive 2 doses of varice a vaccine given at least 4 weeks apart.

). Measles vaccine is given at 9 Given. Subcutaneously ! SQ SQ months of age but may be given as early as 6months of ag $ in cases of outbreak.

0 neumococcal neumococcal Vaccin 1 5 epa epa"" s B ! ! ! ! ! !

KILLED / Inactivated Vaccine Given at birth Follows 0!1!6 schedule ROUTE: Intramuscular " IM IM # DOSE: 0.5 cc ADVERSE ADVERSE REACTION: REACTION: - Pain at injection site - Fever ! greater than or equal to 37.7 ºC - Allergic reactions

prev. ped health care handbook, 2010 ! : ! $ accdg to prev. &

Given IM. The first is given within 12hours of life. Th$ Hepa% B birth dose may be used as the first dose in a 3% dos dos$ primary series. Doses are given at least 4 weeks apart. A fourth dose is need for: $ If 3 rd dose is given at age less than 6 months t he EPI schedule of 6, $ If no birth dose is given using the 10, 14 weeks For preterms less than 2kgs. The initial dose should no( $ For be counted in a 3% dose dose immunization schedul $ $


! ! ! ! !

23 ! Valent Valent Polysaccharide Polysaccha ride Vaccine Vaccine " >2 >2 yo # 7 Valent Conjugate vaccine " < 2 yo # DOSE: 0.5 ml; 3 doses ROUTE: IM or SQ ADVERSE ADVERSE REACTI REACTION: ON: - Mild erythrema - Pain at injection site - Fever

prev. ped health care handbook, handbook, 2010 ! : ! $ accdg to prev. &

Given IM. The minimum age for Pneumococcal ) is 6 weeks and for Conjugate Vaccine ! PnC P nC V ) is at 2 years Pneumococcal Polysaccharide Polysaccharide Vaccine ! PPV old. PPV is recommended for high risk children . 2 years of age in addition to PnCV. For healthy children, no additional doses are needed if PnCV series is complete. complete.

8 otaviru & ! Live Attenuated vaccine ! 2 types available in the market: • ROTARIX ! Follows a 2 dose schedule ! should be

completed at 6 months of life • ROTATEC ! Follows a 3 dose schedule ! last dose should be given until 8 months; approved in the US

! $ accdg to prev. ped health care handbook, 2010 ! Hepa (A:

...cont. Rotavirus

&

!

$ accdg to prev. ped health care handbook, 2010 ! : &

&

Given per orem ! PO ). The monovalent human rotavirus / accine ! RV1 ) is given as a 2dose series. The pentavale , human bovine rotavirus vaccine ! RV5 ) is given as a 3% dos$ series. 1 s dos" % administered # om 6weeks to 14weeks & 6days there is insu 0 cient data on safety of 1 s dose of rotavirus / accine in older infants. The minimum interval bet doses is 4 WEEKS! 2nd dos" % RV1 should not be administered later than 24 *eeks of ag $ 3rd dos " % of RV5 hould not be administered later than 32 *eeks of age! 8 months ) !

!

&

&

!n 6 uenza ,6 u - vaccin1 ! Inactivated vaccine ! Given at 6 months ! Recommended to be given early:

< 3 yo: need 2 shots 1 month apart " 0.25ml/IM #  > 3 yo: 1 dose " 1 shot/year # " 0.5ml/IM # 

! ADVERSE REACTION: - Pain from site of injection - Fever

! $ accdg to prev. ped health care handbook, 2010 ! : &

&

&

Given IM or SQ. A ' children # om 6 months to 18 years should receive influenza vaccine. Children 6 months to 8 years receiving the influenza vaccine for the first tim$ should receive 2 doses of vaccineseparated by at leas( 4WEEKS. If only one dose was administered during previous influenza season, administer 2 doses of the vaccin$ and one therea & er. Children who receive a single dose of influenza vaccine for 2 consecutive years, should continue receiving annual singl $ doses Yearly vaccination % preferably February % Jun$

5 epa"" s 9 ! ! ! !

! ! ! !

Inactivated Vaccine Routine Given beginning 1 yo Follows 2 dose schedule: • 1st ! 1 year old • 2nd ! 6!12 months later ROUTE: Intramuscular " IM # DOSE: 0.5 ml / IM Cut o$ age: 19 yo and above ! 1ml/IM ADVERSE REACTION: - Pain & swelling at injection site


Given IM. Hepa %A is recommended for children 12 months and above. A second dose of the vaccine is give, 6 %12 months a& er the first dose.

5 uman Papi * omavirus , HPV vaccine ! Recently became a routine vaccine ! 2 types: • GARDASIL ! Genital and oral ! 0, 2, 6 ! Quadrivalent " has 4 strains #: ! 6, 11, 16, 18 ! 6 and 11 ! genital warts

• CERVARIX ! Genital ! 0, 1, 6 ! Bivalent " has 2 strains #: ! HPV 16 and 18 ! 16 and 18 can cause cancer ! ROUTE: IM or SQ ! $ accdg to prev. ped health care handbook, 2010 ! Hepa (A: & Given IM. Primary vaccination consists of 3 % dose series administered to females 10% 18 years old. Th $ ' ows: recommended schedule is as fo ! Quadrivalent HPV % 0, 2, 6 % Gardasil ! Bivalent HPV % 0, 1, 6 % Cervarix &

&

The minimum interval between the 1 s and the 2 nd dose is at least 1 month and the minimum interval between 2 nd and 3 rd dose is at least 3 months. Use in males 10%18 yo for prevention of anogenital warts is optional !

SPECIAL VACCINES

: yphoid Vaccin1 ! ! ! !

Given at 2 years DOSE: 0.5 ml " 1 dose # ROUTE: Intramuscular " IM # Revaccination after 2!3 years if with continued re ! exposure. ! AGE: 19 months!13 years old: susceptible children ! $ accdg to prev. ped health care handbook, 2010 ! : &

Recommended for travelers to areas where there are high risk of exposure to S. typhi and for persons with # equen( exposure for S. typhi. A single IM dose may be given as early as 2 years of age with revaccination every 2 to 3 years if there is continued exposure to S. typhi.

SPECIAL VACCINES

2 eningococcal Vaccin1 ! Routine immunization is not recommended ! Indicated for children - 2 years old in high risk groups ! Functional / anatomic asplenia ! Terminal complement deficiency ! Beneficial for travelers to hyperendemic countries ! DOSE: 0.5 ml ! $ accdg to prev. ped health care handbook, 2010 ! : &

Given IM or SQ. A single dose of meningococcal vaccine is recommended for a' children aged . 2 years known to be a( risk for disease. In outbreak situations, infants < 2 years ! minimun of 3 months ) may be given 2 doses of the vaccin$ at 3 months apart. Revaccination may be considered 3% 5 years a& er the first dose for persons who remain at high ris + for infection.

abies Vaccin1 8 ! $ accdg to prev. ped health care handbook, 2010 ! : &

&

&

&

& &

Given IM or ID. Anti rabies act of 2007 recommended ) for childre, routine rabies pre%exposure prophylaxis ! PreP aged 5%14 years in areas where there is high incidence of rabies ! incidence > 2.5 human rabies/mi ' ion population ) There are 2 recommended regimens for pre% exposur $ prophylaxis ! PreP ) : a ) IM dose % PVRV 0.5ml of PCEC 1ml on deltoid area on days 0, 7, 21 or 28 b) ID dose % PVRV or PCECV 0.1 ml given in o, deltoid area on days 0, 7, 21 or 28 Rabies vaccine should never be given in the gluteal area because absorption is unpredictable. For ID dose, a repea( dose should be given if vaccine is inadvertently give, subcutaneously. & er completion of 3 doses of rabies vaccines pre exposur $ A prophylaxis, periodic period booster doses in the absence of exposure are NOT recommended for the general population. Any exposure, regardless of interval between re exposur $ and last dose of the vaccine should receive 2 booster doses as fo ' ows: Day 0 % 1 dos$ Day 3 % 1 dos$ ) or ID Doses may be IM ! 0.5ml PVRV or 1ml PCECV ! 0.1ml PVRV or PCECV ). There is no need to give Rabies ). Immune globulin ! RIG

Good Luck Classmates!

“It's what you learn after you know it all that counts.” - John Wooden

End Don’t forget to read Preventive Pediatric Health Care Handbook 2010 :)


Charlene May G. Tingzon



BASIC PEDIATRICS

CMGT :)

ADOLESCENCE DRA. LERM AGUINALDO ADOLESCENCE: WHO DEFINITION

• Aged 10-18 years old and 364 days • Transition period between childhood to adulthood • Period of development. PUBERTY

• A biologic processes in which a child becomes an adult • Appearance of secondary sexual characteristics • Body size increases to adult size • Dev of reproductive capacity • Pubertal changes follow a predictable sequence or pattern • EX: ! MALES: - Circumanal hair ! Pubic hair ! axillary hair ! facial hair ! chest hair straight pubic hair over the mons pubis) PUBERTY AMONG FEMALES ! FEMALES: ! Pubic hair axillary hair " menarche (onset of menstruation) •Between 8-12 years old - Breast growth ! menstruation •Breast budding phase or breast PUBERTY AMONG MALES enlargement - 1st visible sign of PERIODS OF ADOLESCENCE puberty (estrogen stimulation) •Testes enlargement - 1st visible 1. Early - Hallmark of SMR2 but after 2! sign of puberty 2. Middle years menstruation will take - Hallmark of SMR2 3. Late place. •Gynecomastia (breast hypertrophy) •Menarche - 40-65% during SMR 2-3 ADOLESCENCE - Inluenced by nutrition (wt.), - Considered pathologic if it • Triggers from onset of puberty physical activity, genetic. occurs before or after puberty • Increases sensitivity of the 90% - will disappear after 2 - Late menarche is associated pituitary to the pituitary year with chronic diseases gonadotropin releasing hormone •Testicular enlargement ! voice ! - Onset ! 3-4 months now • Pulsatile release of GnRH, LH and broadening of shoulders ! (earlier) due to improved FSH during sleep " increase muscle dev ! hair growth height weaning (nutrition) gonadal androgen & estrogen " ! penile lengthening & (physiologic somatic changes) " •thelarche(breast enlargement) " enlargement ! adams apple sexual maturity rating or Tanner adrenarche/pubarche (pubertal fine Stages

Puberty

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Classification of sex maturity •

•

•

CLASSIFICATION OF SEX MATURITY STATES IN GIRLS

SMR

PUBIC HAIR

BREASTS

1

Preadolescent ! no sexual hair ye!

Preadolescent ! Breast is similar to that of a young child.

2

Sparse, lightly pigmented, straight, medial border of Breast and papilla elevated as small mound, labia diameter of areola increased $ Slight enlargement of breast tissu%

Onset of puberty" lanugo like, fine, thin, and silky pubic hair #

! Breast budding stage first visible sign of puberty; ha & mark of SMR2; 8$12yo

3

Darker, beginning to curl, increased amount

Breast and areola enlarged, no contour separation Continued enlargement $ continued budding and darkening of areola and enlargement of papi & a

4

Coarse, curly, abundant but less than in adult

Areola and papilla form secondary mound

5

Adult feminine triangle, spread to surface of medial thighs

Mature, nipple projects, areola part of general breast contour Mature female breast; secondary mound disappears.


Classification of sex maturity •

•

•

CLASSIFICATION OF SEX MATURITY STATES IN BOYS

SMR

AGE

Pubic hair

Penis

Testes

1

10!11

None

Preadolescent

Preadolescent

2

11!12

Scanty, long, slightly pigmented

Minimal change, enlargement Enlarged scrotum, pink, texture altered

Testicular enlargement ! 1 "isible sign & ha # mark of SMR2 s!

3

12!13

Darker, starting to curl, small amount

4

13!14

Resembles adult type Larger glans and breadth but less quantity, increase in width coarse, curly

Increase in volume; Larger, darker scrotum

5

14!16

Adult distribution, spread to medial surface of thighs

Adult size


Lengthens

Adult size

Larger or slight ! volume

Sequence of maturational events

• Height peaks 6 months prior to weight


Source: nelson’s book of pediatrics

Central Issues EARLY ADOLESCENCE

MIDDLE ADOLESCENCE

LATE ADOLESCENCE

AGE

10 - 13 years old

14 - 16 years old

17 - 20 beyond (WHO: 17-18yo and 364 days)

SMR

1-2

3-5

5

SOMATIC

• Secondary characteristics - Development of breast - Enlargement of genitals in males - Appearance of pubic hair

• Height growth peaks - Growth acceleration and spurts increase - Weight gain parallels linear growth

• Physically mature • Slower growth - due to closing of epiphysis and sternoclavian junction

• Body shape and composition change - Muscle mass increases, 6 months later, more strength - Boys show greater increase in both weight and height - Bone maturation correlates to SMR because epiphyseal closure is under androgenic control - Broadening of shoulders in boys and widening of hips in girls due to hormones (estrogen determined) - Lean body mass ! in boys; " in girls as subcutaneous fat accumulates. - Doubling in breast size and lung vital capacity - BP, BV and Hct increases, heart size increases too. • Acne and odor - Androgenic stimulations of sebaceous and apocrine glands result in acne and body odor - ACNE - apocrine glands enlarges & ! secretions - BODY ODOR - ! growth of axillary hair, ! secretion; !perspiration

• Little gain in weight • Full reproductive capacity - Attainment of adult genitalia; appearance as well as full reproductive capacity is achieved at this time • In males, deepening of voice, laryngeal muscles dev and expansion of chest are complete. • There is appearance of facial and chest hair.

• Beginning rapid growth - Skeletal growth from distal to proximal parts of the body. - This explains clumsiness - big feet & hands; disproportionate

- Eat and sleep a lot because of rapid growth

• Awkward appearance - Gawky look - hands and feet get bigger before the body - Increased daytime sleeping - Long extremities, lean trunks, large hands

• SLEEP patterns & requirements maybe mistakes as laziness.

• Menarche - FACTORS AFFECTING MENARCHE: ! Genetics ! Nutrition - menarche is delayed in malnutrition; occurs early in obese people. ! Physical ! presence

activity - ! PA will delay onset of menarche of chronic disease - will delay menarche

- Onset decreased by 3-4months per decade (occurs earlier now) due to " PA, improved weaning/better nutrition and early biologic maturity.

• Spermarche - Generally, the 1st ejaculation is brought about by masturbation. Later, it may occur spontaneously during sleep (nocturnal emission) - Testosterone increases biacromial diameter, lean body mass and height (height ! before weight)


• The somatic changes in this period are modest by comparison to earlier periods. The final stages of breast, penile, and pubic hair development occur by 17-18 yr of age in 95% of males and females. Minor changes in hair distribution of ten continue for several years in males, including the g rowth of facial and chest hair and the onset of male pattern baldness in a few. Acne occurs in the majority of adolescents, particularly males. !" o #

Nelson Textbook of Pediatrics $

Central Issues EARLY ADOLESCENCE COGNITIVE & MORAL

• Concrete operations • Unable to perceive long term outcome of current decision making • Conventional morality

MIDDLE ADOLESCENCE • Emergence of abstract thought (formal operations) -

- Devt. of moral thinking - power of fear and punishment - perceives right and wrong as absolute & unquestionable - punishment and reward must be fair ! According to Piagetian theory, adolescence marks the transition ! o "

concrete operational thinking # in early adolescenc! $ to formal logical thinking # abstract thought $. ! Formal logical thinking includes the ability to manipulate algebraic expressions, reason ! om known principles, weigh many points of view, think about the process of thinking itself; understand cause & e " ect; th# opposite of concrete thinking. ! Concrete operational thinking - Early adolescents not capable of logical/abstract thinking - Apply to schoolwork but not personal decision

- They do not see beyond themselves - They have difficulty projecting themselves in the future

- They have poor impulse control - They do things without thinking of consequences - They do not understand cause-and-effect SELFCONCEPT / IDENTITY FORMATION

• Preoccupied with changing body • Fantasy and present oriented • Self consciousness about appearance & attractiveness - Elkind’s imaginary audience - they feel that everyone is staring at them • Girls may feel overweight; dieting, risk of depression eg. anorexia nervosa • Media influences sense of identity and cultural norms • Girls, distorted sense of femininity • Boys, with diff self images • School difficulty, body dissatisfaction, and depression • May have adult expectations placed in them


Understands cause and effect relationship Can predict the consequences of actions Start to question and analyze extensively See beyond themselves

LATE ADOLESCENCE • Future-oriented with sense of perspective • Idealism / absolutism • Able to think things through independently • Patriotism, idealism, search for justice - Late adolescents join rallies

- New flexibility of thought can have pervasive effects

• May perceive future implications, but may not apply in decisionmaking

•

- Understand their actions in a moral and legal context, personal code of ethics

• Questioning mores - More self centered •

With the transition to formal logical thinking, middle adolescents start to question and analyze extensively. Young people now have the cognitive ability to understand the intricacy of the world they live in, to see beyond themselves, and to begin to understand their own actions in a moral and legal context. Questioning of moral conventions fosters the development of personal codes of ethics, which may be similar to or different from those of their parents. An adolescent's new flexibility of thought can have pervasive effects on relationships with the self and others $! om Nelson Textbook of Pediatrics %

• Concern with attractiveness • Increasing introspection • "Stereotypical adolescent" - Typical slow, lazy, sleepy, clumsy • Middle adolescents are more accepting of their own body changes and become preoccupied idealism in exploring future options. Affiliation a peer group is an important step in confirming one's identity and self-image. It is normal for middle adolescents to experiment with different personas, changing styles of dress, groups of friends, and interests from month to month. Many philosophize about the meaning of life and wonder, "Who am I?" and "Why am I here?" Intense feelings of inner turmoil and misery are c ommon. Girls may tend to characterize themselves and their peers according to interpersonal relationships ("I am a girl with close friends."), whereas boys may focus on abilities ("I am good at sports."). Adolescents of both genders, but especially b oys, who develop later than their peers may experience poorer self-image and have higher rates of difficulty in school. $! om Nelson Textbook of Pediatrics %

• • • •

Cognition tends to be less self-centered, with increasing thoughts about concepts such as ju st ic e, pa tr io ti sm , an d hi st or y. Ol de r adolescents are more future-oriented and able to act on long-term plans, delay gratification, compromise, set limits, and think independently. Older adolescents are often idealistic, but may also be absolutist and intolerant of opposing views. Religious or political groups that promise answers to complex questions may hold great appeal $! om Nelson Textbook of Pediatrics %

More stable body Image Attractiveness may still be of concern Emancipation complete Firmer identity

• With emancipation complete, older adolescents begin the transition to adult roles in work and their relationships. They also have constancy in their emotions. $! om Nelso&

Textbook of Pediatrics %

Central Issues EARLY ADOLESCENCE FAMILY

PEERS

MIDDLE ADOLESCENCE

• Increased need for privacy - privacy is a primary concern • Increased bid for independence - Arguments with parents - Distant from parent of the opposite sex - Turns to peer group as a source of emotional support - Separation from family and peers of the same sex provide extra-familial sense of belongingness

• Conflicts over control and independence • Struggle for acceptance of greater autonomy • Reactivated negativism (from 2yo) may be manifested as rebellion. If there is negativism at early stage, during adolescence, they use this negativism to declare independence from family.

• Seek SAME sex group to counter instability

• • • •

• Conformity and Cliques - Being “in” or feeling of belongingness - Peer group uniform - hair clothes, tattoos, piercing • BOYS peer group - more narcissistic,shared activities, COMPETITION • GIRLS peer group - more of sharing CONFIDENCES


LATE ADOLESCENCE • Emotional and physical separation from family (gradual) • Increased autonomy • Practical independence • Will now return to family as a secure base

• Middle adolescence refers to "stereotypical adolescence." Relationships with parents become more strained and distant due to redirected energies toward peer relationships and separation from the family. Dating can become a lightning rod for parent-child battles, in which the real issue may be the separation from parents rather than the particulars of "with whom" or "how late.” ( ! om Nelson Textbook of Pediatrics "

•

Intense peer group involvement Preoccupation with peer culture Peers provide behavioral example Dating is increased The majority of teenagers progress through adolescence with minimal difficulties rather than experiencing the stereotypical "storm & stress. It is the large minority of adolescents (approximately 20-30%) who do experience stress and struggle through th is period who require support. Adolescents with visible differences are also at risk for problems, such as not developing adequate social skills and confidence and having more difficulty establishing satisfying relationships. ( ! om Nelson Textbook of Pediatrics "

• Peer group and values recede in importance (becomes less important) • Intimacy and possible commitment takes precedence

Central Issues EARLY ADOLESCENCE SEXUAL

• Increased interest in sexual anatomy - Increased sexual awareness and drives

• Anxiety and questions about genital changes - Circumcision - wait for them to volunteer

• Limited dating and intimacy

• Outpouring of sex hormones • Increased sexual awareness: How are these expressed?

- At first, boys are normally isolated from girls. - Girls mature earlier, they tend to e xpress their interest to boys earlier too.

- With onset of adolescence, there is increased sexual

-

RELATIONSHIP TO SOCIETY

interests. Since they cannot show it to opposite sex, they express it through group interaction: ! Boys - athletic activities - Ejaculation occurs - Masturbation - Can be caused by anxiety due to nocturnal ejaculation - Buddy arrangement(twosome) ! Girls - gymnastics - Intense friendship - Physical contact - More aggressive Too high drives are not satisfied, they express their interests to individuals of same sex: girl-girl, boys’ twosome or buddy sys. This may be transient or temporary only.

• Middle school adjustments - Adjustments from elementary (usually have homerooms) to HS (transfer from one room to another; more responsibility and added stimulation)

MIDDLE ADOLESCENCE • • • • • •

Testing ability to attract partner Initial of relationships and sexual activity. Questions of sexual orientation Sexual drive surges result to experimentation (group interaction) Increase sexual hormones Begins to attract individuals of opposite sex (dating)

• Dating becomes a normative activity as middle ado lescents assess their ability to attract others. The degree of sexual activity and its onset vary widely. At age 16yr, approximately 33% of girls and 42% of boys report having oral or vaginal sex. Most adolescents have kissed by age 14 yr (71%). French kissing is more common by age 15 yr, and petting is more common among teen boys at age 16yr (75%),but it catches up with teen girls by age 17yr (76%). Homosexual experimentation is common and does not necessarily reflect a child's ultimate sexual orientation. Many adolescents worry that they might be homosexual and dread being found out. Homosexual adolescents face an increased risk of isolation and depression. In addition to sexual orientation, middle adolescents begin to sort out other important aspects of sexual identity, including beliefs about love, honesty, and propriety. Relationships at this age are often superficial and emphasize attractiveness and sexual experimentation rather than intimacy. Adolescents tend to choose one of three sexual paths: celibacy, monogamy, or polygamous experimentation. Most have some knowledge of the risks of pregnancy, HIV, and other sexually transmitted diseases, but knowledge does not consistently control behavior. Fewer than 70% of adolescents consistently use condoms, and approximately 26% of girls do not use any method of contraception at their first Intercourse. ( ! om Nelson Textbook of

• Consolidation of sexual identity • Focus on intimacy and formation of stable relationships • Planning for future and commitment • Individual, particularly intimate relationships take precedence, providing an important component of identity in older adolescents. In contrast to the often superficial dating relationships of middle adolescence, these relationships increasingly involve love and commitment. ( ! om Nelson Textbook of Pediatrics "

Pediatrics "

• Gauging skills and opportunities

• Career decision(College,work)

- Starts to think what they want in life

• Self assessment & assessment of available opportunities As part of middle adolescents' exploration of future options, they begin to think seriously about what they want to do as adults, a question that formerly had been comfortably hypothetical. The process involves self-assessment and exploration of available opportunities. The presence or absence of realistic role models, as opposed to the idealized ones of earlier periods, can be crucial. ( ! o #

Nelson Textbook of Pediatrics "


LATE ADOLESCENCE

• Career decisions become pressing because an adolescent's self-concept is increasingly bound up in his or her emerging role in society. ( ! o #

Nelson Textbook of Pediatrics "

CRUCIAL TASKS OF AN ADOLESCENT (ERICKSON) • • • •

Establish a stable sense of identity Emotional & physical separation from family of origin Initiation of intimacy Realistic planning for economic independence •

•

•

Medical & Psychosocial Concerns of Adolescence A. SKIN 1. ACNE - Most common skin problem or concern of adolescents - Due to ! secretions of androgen, sebaceous and apocrine glands. - As doctors, we must REASSURE them that this is just part of growing up and TREAT to prevent scars 2. ALLERGY - Should also be addressed.

B. MUSCULOSKELETAL 1. POSTURE - Only few adolescents have good posture - Sudden growth (height) spurt occurs in middle adolescence - Individuals who matured early becomes taller than others and this may bring about feeling of awkwardness. To deviate from others’ attention, they assume a “ slumpy” posture. - Also influenced by emotional, physical, social & cultural factors - Prolonged phone use (telebabad ) ! poor posture - Automobile use decreases exercise ! poor posture

- Development of breast, in females, can lead to poor posture. They tend to deep their shoulders forward to hide the dev breasts. - Rapid skeletal growth leads to imbalance between strength & flexibility ! poor posture

2. EPIPHYSEAL INJURIES - Very common to adolescents - Adolescence is a stage of rapid bone formation - Rapid bone deposition in the epiphyseal plate ! reduced metaphyseal area is reduced and temporarily weakened + heightened sports activities at this stage !!! metaphyseal area is most vulnerable to injury

C. RESPIRATORY 1. PNEUMONIA • Young - VIRAL • Adult - BACTERIAL • Adolescent - Mycoplasma pneumonia!


D. TEETH 1. Dental Caries - Adolescents are fond of eating carbohydrates, sleep most of the time, and lazy that they forget oral hygiene. - Carbohydrates + oral bacteria ! fermentation ! metabolic acids that erode teeth enamel 2. Malocclusion - Due to rapid growth of jaw - Conscious about their appearance - To be “in”

E. CVS 1. Fatigue - It is very important to differentiate adolescents who are tired all the time vs those who really gets tired easily - Tired all the time active and willing to work when away from family; psychologic - Gets tired easily - tired with or not with family; pathophysiologic; can be due to PTB, anemia (IDA) and anxiety.

F. GENITOURINARY 1. Teenage pregnancy ! FACTORS: - Early biologic maturity - Misconceptions - Girls who have single-parent; less parental supervision; ! chance of early pregnancy - Girls with more matured parents (stricter) have less chance of early pregnancy. - Girls with high educational aspirations have less chance of early pregnancy - Girls with strong religious beliefs have less chance of early pregnancy ! CONSEQUENCES

OF EARLY PREGNANCY - Fathers - tend to have more behavioral and academic problems - Mothers - have to be independent; poorly educated; repeated unwanted pregnancies - These will result to high infant morbidity and mortality

2. Sexually Transmitted Disease - Increased bec of premature sexual activity - Gonorrhea - 1st most common - Chlamydia - 2nd most common

G. NUTRITION

HEADS/S F/FIRST

1. Obesity - Best defined as excessive accumulation of fats - Not just about excessive weight because increased weight may be due to muscle mass.

- Management: lifestyle change which includes change in both behavior and diet. - Can lead to emotional problems - Obese individuals tend to withdraw from society and social activities which may cause them to eat more as a relief.

2. Anemia - In middle adolescence, there is inclease in bloop pressure and blood volume. Iron content of the blood is diluted ! IDA - Iron Deficiency Anemia- hypochromic, microcytic

- Early signs: ! Poor school performance ! Decrease

attention span ! With or without pallor H. EMOTIONAL OR PSYCHIATRIC DISORDER

1. Anorexia nervosa - Eating disorder; Fear of being fat - There is misperception of their body shape and size. 15% below IBW but they feel fat. - Secondary effects: Malnutrition, cessation of menstruation (amenorrhea), and electrolyte imbalance. 2. Bulimia nervosa - Afraid to eat but once they eat, they become uncontrollable & eat everything (binge eating)! - After, they will do calorie reducing activity like self induced vomiting vigorous activities " take in laxatives. " "

3. Suicide - Adolescents experience a lot of stress, any additional stress (like ending a relationship) is difficult for them " suicidal attempts - Females - suicidal attempt only - Males - carry out suicide I. HIGH RISK BEHAVIOR # Volitional

behavior with identifiable negative outcome

# These

2 are interrelated and responsible for >50% of mortality and morbidity among adolescents # Adolescents are vulnerable to these because these are characterized by physical, social, cognitive and environmental change. # More intense effect in boys (biologic effect of testosterone)

1. Substance use/abuse - Alcohol, cigarettes, drugs - 50% due to curiosity and peer pressure 2. Premature Sexual Activity - May be due to: - Peer pressure, lack of knowledge, lack of preparation, single parent, religiosity, low educational background 3. Motor Vehicle Recreation - Driving under the influence of drugs and alcohol

Teens & Technology • Teens are shy people (easily embarrassed) • Best person to consult to is a DOCTOR.PEDIATRICIAN • Understand their wish for confidentiality


H-Home separation, support, space to grow, privacy, frequent geographic moves, neighborhood E-Education/Employment - expectation, study habits, after school activities, school performance, achievements, aspirations - frequent school changes, repetition of a grade,/ in each subject, teachers’ reports, vocational goals, after-school education clubs(language, speech, math, etc), learning disabilities A -Abuse - emotional, physical, sexual, verbal abuse:parental discipline D-Drugs - tobacco, alcohol, marijuana, cocaine, “club drugs”, “rave” parties, others - DOC, age @ initiation, frequency, mode of intake, rituals, alone or with peers, quit methods and # of attempts (obtain detailed history) S-Safety

-

Seat belts, helmets, sport safety measures, hazardous activities, driving while intoxicated S-Sexuality/ Sexual Identity - Reproductive health(use of Contraceptives, presence of STD, feelings, pregnancy) F-Family - Family constellation, genogram, single/married/ separated/divorced/blended family, family occupations and shifts; history of addictions of 1st and 2nd degree relatives, parental attitude toward alcohol and drugs, parental rules; chronically ill physical or mentally challenged parent F-Friends - Peer cliques and configuration(preppies, jocks, nerds, computer geeks, cheerleaders), gang or cult affiliation I-Images

-

Self-steem, looks, height and weight perceptions, body musculature and physique, appearance (including dress, jewelry, tattoos, body piercing, as trends or other statements); acceptance R -Recreation - Exercise, sleep, organized or unstructured sports, recreational activities(tv, video games, computer games, internet and chat rooms, church, or community youth group activities - How many hours per day? Days per week involve? S-Spirituality and connectedness - Use HOPE or FICA acronym; adherence, rituals, occult practices, community service or involvement HOPE H-hope or security for the future ! O-organized religion ! P-personal spirituality and practices ! E-effects on medical care and end of life ! issues FICA F-faith beliefs !

-

•

•

! !

I-importance and influence of faith C-community support

T-Threats and Violence - Self harm or harm to others, running away, cruelty to animals, guns, fights, arrests, stealing, fire setting, fights in school

BASICPEDIA-complete (1).pdf

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